D052 - Navigating Care Across the Continuum Study guide Graded A

D052 - Navigating Care Across the Continuum Study guide Graded A Define compliance is the process of following rules, regulations, and laws that relate to healthcare practices. Compliance in healthcare can cover a wide variety of practices and observe internal and external rules. What is the importance of accurate documentation? Good documentation is important to protect your patients. Good documentation promotes patient safety and quality of care. Complete and accurate medical recordkeeping can help ensure that your patients get the right care at the right time. Why is noncompliance an important concern for health service coordinators? is the willful refusal to follow recommended care plans and can be the result of many different circumstances What are bundle payments? is the reimbursement of health care providers (such as hospitals and physicians) "on the basis of expected costs for clinically-defined episodes of care." What is the purpose of clinical reviews? Clinical care review is the process of retrospectively examining potential errors or gaps in medical care, with a goal of future practice improvement. What is HEDIS? Healthcare Effectiveness Data and Information Set, comprehensive set of standardized performance measures designed to provide purchasers and consumers with the information they need for reliable comparison of health plan performance. Explain Third Party Insurance Reimbursement Third-party payers pay for covered insurance expenses for an insurance recipient or a designated beneficiary. Co-insurance Requires the insured individual to pay a fixed percentage of the loss after the deductible has been paid Co-payment a specific amount of money a patient pays for a particular service deductible Amount you must pay before you begin receiving any benefits from your insurance company capitation payment to a provider that covers each plan member's health care services for a certain period of time InterQual Clinical decision support tool determines when and how a patient progresses through the continuum. - organizes resources utilization, - objective evidence based criteria for assessing appropriate care for patients. Helps fraud/abuse patient centered medical home PCMH a care delivery model whereby patient treatment is coordinated through their primary care physician to ensure they receive the necessary care when and where they need it, in a manner they can understand QI process Collecting data Analyzing data Stating goals/objectives Action to change Evaluate why is accreditation important? if there is any time of scholarships or money that a person wants to receive, they must attend an accredited school What is the process of credentialing? is the process of obtaining, verifying, and assessing the qualifications of a practitioner to provide care or services in or for a health care organization. Credentials are documented evidence of licensure, education, training, experience, or other qualifications. HIPAA risk Assessment identify and document vulnerabilities within their business. Performing a security risk analysis is the first step to identify vulnerabilities that could result in a breach of PHI. How do standards improve healthcare? The main purpose of professional standards is to direct and maintain safe and clinically competent nursing practice. These standards are important to our profession because they promote and guide our clinical practice. What is computer literacy and what does it mean? knowledge and ability to use computers and technology efficiently. HITECH Act - Health Information Technology for Economic and Clinical Health Act encouraged healthcare providers to adopt electronic health records and improved privacy and security protections for healthcare data. What are the benefits of health IT for improving care? Achieve Practice Efficiencies & Cost Savings. Improve Care Coordination. Improved Diagnostics & Patient Outcomes. Improved Patient Care. Increase Patient Participation. EHR (electronic health record) a digital version of a patient's paper chart How do EHR's benefit clinicians and patients? Helping providers more effectively diagnose patients, reduce medical errors, and provide safer care. Improving patient and provider interaction and communication, as well as health care convenience. Health Information Exchange (HIE) an electronic system that allows physicians, nurses, pharmacists, other health care providers, and patients to appropriately access and securely share a patient's vital medical information What are some safeguards you can use when using mobile devices? Strong passwords coupled with biometric features, such as fingerprint authenticators, make unauthorized access nearly impossible. Ensure public or free Wi-Fi is protected. Utilize VPN Encrypt your device. Install an Antivirus application Update to the latest software. What can happen if you or your organization violate HIPAA or PHI? The minimum fine for willful violations of HIPAA Rules is $50,000. The maximum criminal penalty for a HIPAA violation by an individual is $250,000. Criminal violations that occur as a result of negligence can result in a prison term of up to 1 year. HIPAA Privacy Rule Law that regulates the use and disclosure of patients' protected health information (PHI). medical coding The set of symbols and numbers used to communicate specific treatments and diagnoses between a care facility and payment provider RAC audits (Recovery Audit Contractor) A RAC audit was created through the Medicare Modernization Act of 2003 (MMA) to identify and recover improper Medicare payments. Medicaid Integrity Contractors MIC entities with which CMS has contracted to conduct post-payment audits of Medicaid providers. What is upcoding and its impact on the healthcare organization? While it is not the norm by any means, upcoding can occur when you receive diagnostic services, medical procedures, or visit your healthcare provider. The consequence of upcoding is an increased cost of health care for everyone because the government and private payers distribute the cost of healthcare among everyone. What is down coding and its impact on the healthcare organization? Down coding means you're not maximizing reimbursement for your healthcare organization. You're either not claiming money you earned, or you're setting yourself up to have to spend time on reworking claims to get the correct reimbursement. What are the three types of scientific studies that can be used when selecting an evidence-based practice (EBP) to implement? 1) the best external evidence, 2) individual practitioner's clinical expertise, and 3) patients' preference. Evidence Based Medicine medical care based on the latest and most accurate clinical research evidence-based practice clinical decision making that integrates the best available research with clinical expertise and patient characteristics and preferences Evidence based care Delivery of care that incorporates the use of best practices that have been evaluated for effectiveness and safety through clinical research. Best practices are often found in clinical practice guidelines. evidence-based management involves making decisions based on hard facts about what really works EBM pyramid 1. Background information and Expert Opinion 2. Case series and Case Reports 3. Case-control studies 4. Cohort studies 5. RCTs 6. Systematic reviews 7. Meta-analysis EBP Triad Individual Clinical Expertise Best External Evidence Patient Values and Expectations Medicare signed into law July 30, 1965 Which three steps are required to develop a new drug that may become an evidence- based practice (EBP) drug of choice? Step 1: Preclinical research Step 2: Clinical research Step 3: Post-clinical research Scientific Method Steps Question, Research, Hypothesis, Experiment, Analyze the Data, Conclusion Accountable Care Organization (ACO) An organization of healthcare providers accountable for the quality, cost, and overall care of Medicare beneficiaries who are assigned and enrolled in the traditional fee-for-service program Medical Practice Acts State laws written for the express purpose of governing the practice of medicine informed consent an ethical principle that research participants be told enough to enable them to choose whether they wish to participate 4 principles of HIPAA Consumer control. Patients have new rights to control the release of their medical information. Boundaries. ... Accountability. ... Public Responsibility. ... Security. Tort Law Law that deals with harm to a person or a person's property. Quality Improvement opportunities A QI program is a set of focused activities designed to monitor, analyze, and improve the quality of processes in order to improve the healthcare outcomes in an organization. What is LTC long term care What is the resident assessment instrument and minimum data set (RAI/MDS)? The Resident Assessment Instrument-Minimum Data Set (RAI-MDS) is designed to collect the minimum amount of data to guide care planning and monitoring for residents in long-term care settings. These data have been used to compute indicators of care quality. What is the dyad model? defines collaboration care between care leaders, such as an administrative and a clinical leader What is the triad model? a case manager, social worker, and utilization review specialist collaborate on care. What is the goal of modern case management that operates as a collaborative partnership between professionals? assess a client's needs, develop a plan of care, work with partners to coordinate care, evaluate the effectiveness of care, and advocate for a patient in ways that address the socioeconomic and psychosocial influences on health Why is collaboration among teams important? Team building activities will bring positive impact on office culture as it will improve communication, motivate employees, increase productivity, and help employees to get to know each other better What are some of the skills and strengths of healthcare professionals? Empathy, Communication Skills, Teamwork, Work Ethic, Stress, Management, Positive Attitude, Flexibility What are some examples of vulnerable populations? include the economically disadvantaged, racial and ethnic minorities, the uninsured, low-income children, the elderly, the homeless, those with human immunodeficiency virus (HIV), and those with other chronic health conditions, including severe mental illness. What role does the health services coordinator play in assisting vulnerable populations? Create connections between vulnerable populations and healthcare providers. Help patients navigate healthcare and social service systems. Reduce social isolation among patients. motivational interviewing a collaborative, person-centered form of guiding to elicit and strengthen motivation for change active listening Empathic listening in which the listener echoes, restates, and clarifies. A feature of Rogers' client-centered therapy. What is the screening, brief intervention, and referral to treatment (SBIRT) approach? evidence-based approach to identifying patients who use alcohol and other drugs at risky levels What is the solution-focused approach? Solution-Focused Brief therapy (SFBT) is a future-oriented, goal-directed approach to solving human problems of living What is the benefit of a task analysis? task analysis makes employees aware of why they need to complete each step to the best of their ability and what can happen if they do not. Reduces on-the-job mistakes. A task analysis increases productivity, streamlines work processes, and clarifies every aspect of a task. What are the 10 strategies for motivational interviewing? 1. Ask a question 2. Pros/ cons for changing 3. Pos/neg for target behavior 4. change talk details 5. ask about before care 6. ask what may happen with change 7. ask about extreme outcomes 8. offer ways to measure care 9. main health goals 10. reframe barriers into positive personal health record (PHR) information sheets that contain the individual's medical history, including diagnoses, symptoms, and medications Telehealth services These services use electronic and communication technology to deliver medical information and services over large and small distances through a standard telephone line. interdisciplinary team professionals from each discipline within the nursing facility who meet to discuss and plan the care of the resident What is a care plan? outlines the steps and tasks the care team must perform Care plan includes assessment, diagnosis, expected outcomes, interventions, rationale and evaluation Who is the most important partner in the care plan? the patient What is the benefit of the medical community supporting the family as partners in the care plan? Patient and family involvement in decision making has been associated in primary care settings with reduced pain and discomfort, faster recovery in physical health, and improvements in emotional health Benefits of a diverse care team Increased provider comfort levels: Studies show that students who have trained at diverse schools are more comfortable treating patients from ethnic backgrounds other than their own. Boosted creativity and innovation: A wide range of perspectives can lead to better solutions. teach back method allows patient to repeat back key concepts from teaching session to confirm understanding Ask-Tell-Ask is a back-and-forth cycle between the patient and health professional that addresses four essential components Triple Aim -Improve the health of the population -Enhance the patient experience of care -Reduce or control the per capita cost of care What is the Quadruple Aim? 1. Better outcomes 2.Lower costs 3.Improved clinician experience 4.Improved patient experience What are the core competencies related to roles and responsibilities of members on an interdisciplinary care planning team? communication, leadership, professionalism, knowledge, and business skills What is benchmarking and how can it help the care coordinator? The purpose of benchmarking in healthcare is to improve efficiency, quality of care, patient safety and patient satisfaction What is value-based care in treatment planning? is a health care delivery model under which providers — hospitals, labs, doctors, nurses and others — are paid based on the health outcomes What are some of the responsibilities of a health service coordinator? oversee the organizational aspects of patient care in healthcare organizations. They wear many hats, with responsibilities like planning and coordinating the medical and health services in their scope of influence. Task-Centered Practice aims to quickly engage clients in the problem-solving process to maximize their responsibility for treatment outcomes, focus is 'here and now', immediate results third party insurance reimbursement This includes payment for medical expenses owed to a health care provider or to the insured for reimbursement when the insured incurs covered out-of-pocket expenses. Pay for performance bases pay on one's results What is a patient-centered medical home (PCMH) and why is it important to the interdisciplinary team? The Patient-Centered Medical Home (PCMH) is a care delivery model whereby patient treatment is coordinated through their primary care physician to ensure they receive the necessary care when and where they need it, in a manner they can understand. Forming the first stage of team development, in which team members meet each other, form initial impressions, and begin to establish team norms norming the third stage of team development, in which team members begin to settle into their roles, group cohesion grows, and positive team norms develop storming the second stage of development, characterized by conflict and disagreement, in which team members disagree over what the team should do and how it should do it performing members concentrate on solving problems and completing the assigned task adjourning members prepare for disbandment What are the nine skills needed for effective communication? Be direct. Listen. Write accurate and clear business emails. Show respect. Be positive. Be understanding Don't criticize Avoid arguments. Make meetings important The goal of shared decision-making is to enhance or restore a patient's autonomous capacity, while paying closer attention to the emotional and relational dimensions of care. What are the three steps of shared decision-making? a) introducing choice, b) describing options, often by integrating the use of patient decision support, and c) helping patients explore preferences and make decisions What are some ways you can improve nonverbal communication? Pay Attention to Nonverbal Signals. Look for Incongruent Behaviors Focus on Tone of Voice Use Good Eye Contact Ask Questions Use Signals to Add Meaning Look at Signals as a Whole