ATI Fundamentals of Nursing 2025 |
Comprehensive Guide to U.S. Healthcare
Delivery Systems, Insurance Models, and Levels
of Care | Verified Notes & Exam Prep for PN &
RN Students
Medicare - for clients over age 65 and/or with permanent disabilities. premiums applied as
insurance program reimburses providers based on DRGs. Premiums applied as Managed Care
Organizations (MCOs) provide enrolled clients with comprehensive care overseen by a primary
care provider. Is federally funded.
Medicaid - for clients with low income. is federally funded and individual states determine
eligibility requirements.
Traditional Insurance - reimburses for services on fee-for-service basis.
Managed Care Organizations (MCOs) - comprehensive care is overseen by a primary care
provider & focuses on prevention and health promotion
Preferred Provider Organizations (PPOs) - client chooses from a list of contracted providers.
using non-contracted providers increases the client's out of pocket costs
Exclusive Provider Organizations (EPOs) - the client chooses from a list of providers within a
contracted organization
Long-Term Care Insurance - provides for long-term care expenses not covered by Medicare
,Preventive health care - focuses on educating and equipping clients to reduce and control risk
factors of disease. Examples include immunizations, stress management programs, and seat
belt use
,Primary health care - emphasizes health promotion, and includes prenatal and well-baby care,
nutrition counseling, and disease control. is based on a sustained partnership between client
and provider. examples include office or clinic visits and scheduled school/work centered
screenings (vision, hearing, obesity)
Secondary health care - includes the diagnosis and treatment of emergency, acute illness, or
injury. examples include care given in hospital settings (inpatient and EDs), diagnostic centers,
or emergent care centers
Tertiary health care - involves the provision of specialized highly technical care. examples
include oncology centers and burn centers
Restorative health care - involves intermediate follow-up care for restoring health. examples
include home health care, rehab centers, and skilled nursing facilities
Continuing health care - designed to address long-term or chronic health care needs. examples
include hospice, adult day care, and in-home respite care
Health care regulatory agencies include: - -US Dept of Health and Human Srvcs
-US FDA
-State and local public health agencies
-State licensing boards (to ensure providers & agencies comply with state regulations)
-the Joint Commission/JCAHO (set quality standards for accreditation of health care facilities)
-Professional Standards Review Organizations (PSROs)
-Utilization review committees (monitor for appropriate diagnosis and treatment of hospitalized
clients)
Clergy - Job: provide spiritual care to client (pastors, rabbis, priests)
, Refer to when: the client requests communication or the family asks for prayer prior to client
undergoing a procedure
Registered dietitian - Job: assess, plan for, and educate the client reg. nutritional needs; direct
care of nutritional aids
Refer to when: ex- the client has low nutrient levels and/or experienced a recent unexplained
weight loss
Lab tech - Job: obtain specimens of the client's body fluids and perform the necessary
diagnostic tests
Refer to when: ex- the provider orders a CBC to be performed immediately
Occupational therapist - Job: assess and plan for the client to regain ADLs, esp motor skills of
the upper extremities; direct care of occupational therapy assistants
Refer to when: ex- client has difficulties using an eating utensil with dominate hand following a
stroke
Pharmacist - Job: provide & monitor meds for the client as prescribed by the provider;
supervises pharm techs in states in which the practice is allowed
Refer to when: client concerns over meds; dosage concerns; etc
Physical Therapist - Job: assess and plan for client to increase musculoskeletal functions, esp
of lower extremities, to maintain mobility; direct care of physical therapy assistants
Refer to when: ex- following a hip replacement, a client requires assistance learning to ambulate
and regain strength
Comprehensive Guide to U.S. Healthcare
Delivery Systems, Insurance Models, and Levels
of Care | Verified Notes & Exam Prep for PN &
RN Students
Medicare - for clients over age 65 and/or with permanent disabilities. premiums applied as
insurance program reimburses providers based on DRGs. Premiums applied as Managed Care
Organizations (MCOs) provide enrolled clients with comprehensive care overseen by a primary
care provider. Is federally funded.
Medicaid - for clients with low income. is federally funded and individual states determine
eligibility requirements.
Traditional Insurance - reimburses for services on fee-for-service basis.
Managed Care Organizations (MCOs) - comprehensive care is overseen by a primary care
provider & focuses on prevention and health promotion
Preferred Provider Organizations (PPOs) - client chooses from a list of contracted providers.
using non-contracted providers increases the client's out of pocket costs
Exclusive Provider Organizations (EPOs) - the client chooses from a list of providers within a
contracted organization
Long-Term Care Insurance - provides for long-term care expenses not covered by Medicare
,Preventive health care - focuses on educating and equipping clients to reduce and control risk
factors of disease. Examples include immunizations, stress management programs, and seat
belt use
,Primary health care - emphasizes health promotion, and includes prenatal and well-baby care,
nutrition counseling, and disease control. is based on a sustained partnership between client
and provider. examples include office or clinic visits and scheduled school/work centered
screenings (vision, hearing, obesity)
Secondary health care - includes the diagnosis and treatment of emergency, acute illness, or
injury. examples include care given in hospital settings (inpatient and EDs), diagnostic centers,
or emergent care centers
Tertiary health care - involves the provision of specialized highly technical care. examples
include oncology centers and burn centers
Restorative health care - involves intermediate follow-up care for restoring health. examples
include home health care, rehab centers, and skilled nursing facilities
Continuing health care - designed to address long-term or chronic health care needs. examples
include hospice, adult day care, and in-home respite care
Health care regulatory agencies include: - -US Dept of Health and Human Srvcs
-US FDA
-State and local public health agencies
-State licensing boards (to ensure providers & agencies comply with state regulations)
-the Joint Commission/JCAHO (set quality standards for accreditation of health care facilities)
-Professional Standards Review Organizations (PSROs)
-Utilization review committees (monitor for appropriate diagnosis and treatment of hospitalized
clients)
Clergy - Job: provide spiritual care to client (pastors, rabbis, priests)
, Refer to when: the client requests communication or the family asks for prayer prior to client
undergoing a procedure
Registered dietitian - Job: assess, plan for, and educate the client reg. nutritional needs; direct
care of nutritional aids
Refer to when: ex- the client has low nutrient levels and/or experienced a recent unexplained
weight loss
Lab tech - Job: obtain specimens of the client's body fluids and perform the necessary
diagnostic tests
Refer to when: ex- the provider orders a CBC to be performed immediately
Occupational therapist - Job: assess and plan for the client to regain ADLs, esp motor skills of
the upper extremities; direct care of occupational therapy assistants
Refer to when: ex- client has difficulties using an eating utensil with dominate hand following a
stroke
Pharmacist - Job: provide & monitor meds for the client as prescribed by the provider;
supervises pharm techs in states in which the practice is allowed
Refer to when: client concerns over meds; dosage concerns; etc
Physical Therapist - Job: assess and plan for client to increase musculoskeletal functions, esp
of lower extremities, to maintain mobility; direct care of physical therapy assistants
Refer to when: ex- following a hip replacement, a client requires assistance learning to ambulate
and regain strength
