Chapter 1: Understanding Healthcare Settings

Learning Objectives Discuss the structure of the healthcare system in regards to past, present, and future Describe a typical long-term care facility Describe residents who live in long-term care facilities Explain policies and procedures Describe the long-term care survey process Differentiate between Medicare and Medicaid Discuss the terms culture change, person-directed care, Pioneer Network, and The Eden Alternative By the time you are done with this course, you should be able to: 1) Discuss the structure of the healthcare system in regards to past, present, and future, 2) Describe a typical long-term care facility, 3) Describe residents who live in long-term care facilities, 4) Explain policies and procedures, 5) Describe the long-term care survey process, 6) Differentiate between Medicare and Medicaid, and 7) Discuss the terms culture change, person-directed care, Pioneer Network, and The Eden Alternative.

Traditional Healthcare system The term healthcare system refers to all of the different types of providers, facilities, and payers involved in the delivery of medical care. Providers are people or organizations that provide medical care (ie. Doctors, nurses, clinics, and other agencies). Facilities are places where medical care is provided or administrated (ie. Hospitals, long-term care facilities, and treatment centers). Payers are the people or organizations that pay for healthcare services. These include private insurance companies, government programs (Medicare and Medicaid), and the individual, themselves. There is an overall rising cost for healthcare. This is, in part, due to the increased use of expensive technologies in disease prevention, diagnosis, and treatment. The healthcare system has implemented several strategies to decrease the cost of healthcare. The first is the development of health maintenance organizations (HMOs) which require participants to use a particular doctor or group of doctors unless there is an emergency. These doctors work to keep costs down for both the insurance company and its participants by seeing more patients, ordering fewer tests, etc. Another cost-reducing healthcare option is preferred provider organizations (PPOs). In PPOs, providers contract to provide healthcare to a group of people (usually an employer and its employees) and charges are care is charged at a reduced fee-for-service rate. A participant may choose to seek care outside of the PPO, however he or she must pay a higher portion of the cost. Both HMOs and PPOs are often referred to as managed care. Managed care seeks to make people well in the most efficient and least expensive way.

The typical long-term care facility Long-term care facilities (LTCFs) Activities of daily learning (ADLs) Therapies Wound care Care of different tubes Nutrition therapy Management of chronic diseases Long-term care facilities are businesses that provide 24-hour skilled nursing care to its clients. The typical long-term care offers personal care, or activities of daily living (ADLs), for all residents. ADLs include bathing, skin, nail and hair care, and assistance with walking, eating, dressing, transferring, and toileting. While these services are provided to all residents at a level required by each individual, residents with special needs can obtain needed services at long-term care facilities, as well. Some examples include therapies (IV medications, cancer treatments, etc.), wound care, care of different tubes, nutrition therapy, and management of chronic diseases.

Residents who live in long-term care facilities Age Gender Race Residence prior to admission Length of stay 89% of residents are over 65, 54% are over 85 and 11% of residents are younger than 65. 70% of residents are female, and more than 90% are white and non-Hispanic. 1/3 of residents have come from a private residence and over 50% came from a hospital. Over 2/3 of residents in long-term care have a length-of-stay of 6 months or longer. Developmentally disabled persons have the longest average stay. Residents who have a length of stay of less than 6 months are admitted for either terminal care (patients who will likely die in the facility) or those admitted for rehabilitation or temporary illness. Dementia and other mental disorders are also causes of admissions to long-term care facilities. Most residents enter a long-term care facility because of their lack of ability to care for themselves and the lack of support from their family and community. The kinds of care needed is dependent on the reason residents are admitted.

Policies and procedures Policy vs. procedure Common policies First, let’s distinguish between the terms policy and procedure. A policy is a course of action taken every time a certain situation takes place. A procedure is a method of doing something. Some common policies at long-term care facilities include: All resident information is confidential Resident’s care plans must be followed NAs only perform tasks in job descriptions NAs report to nurse NAs should not discuss personal problems with residents or families NAs should not accept gifts and money from residents or families NAs must be dependable

Long-term care survey process The Joint Commission Long-term care facilities and home health agencies must follow state and federal regulations. Surveys are inspections conducted by state agencies that license facilities. Surveys involve interviews of residents and their families, observation of staff interactions with residents and care given, review of residents’ charts, and observation of residents’ meals. A citation is issued when a problem is found through the survey process. NAs should always tell the truth when questioned by surveyors. If a NA doesn’t know the answer to questions, he or she should not guess. The Joint Commission is an independent organization that evaluates and accredits healthcare organizations that choose to voluntarily participate. Joint Commission surveys are not affiliated with state inspections.

Medicare and Medicaid Centers for Medicare & Medicaid Services (CMS) Part A Part B Part C Part D Medicaid The Centers for Medicare & Medicaid Services is the federal agency within the U.S. Department of Health and Human Services that runs both Medicare and Medicaid. Medicare is a health insurance program for people 65 years of age or older or those with disabilities and illnesses. Medicare Part A helps pay for care in a hospital or skilled nursing facility or for care from a home health agency or hospice. Part B helps pay for doctor devices and other medical services and equipment. Part C allows private health insurance companies to provide Medicare benefits. Part D helps pay for medications prescribed for treatment. Medicaid is funded by both the federal and state governments. Eligibility for Medicaid is determined by income and special circumstances. People must qualify for Medicaid services. Both Medicare and Medicaid provide coverage for long-term care at a fixed rate for services. Services are based on the resident’s needs upon admission.

Culture change, person-directed care, Pioneer Network, and the Eden alternative Choice Dignity Respect Self-determination Purposeful living Pioneer Network Person-directed care Eden Alternative Culture change is a term given to the process of transforming services for elders so that they are based on the values and practices of the person receiving care. These include providing choice, preserving dignity, giving respect, allowing for self-determination and purposeful living. These principles apply to both residents and the people working with them. The Pioneer Network was formed in 1997 by a small group of people in long-term care who were advocates for person-directed care (emphasizes the individuality of the person who needs care and seeks to build community by recognizing and developing each person’s capabilities). This network called for change in how elders are treated everywhere in the community. The Eden Alternative is an organization that was founded in 1991 by Dr. William Thomas to focus on improving the lives of elders and their caregivers. This is done by creating environments that support growth and development, and that eliminate loneliness, helplessness, and boredom of these individuals. The organization offers education, resources, and consulting services.

Review Structure of healthcare Long-term care facility Residents who live in long-term care facilities Policies and procedures Survey process Medicare and Medicaid Culture change, person-directed care, Pioneer Network, and The Eden Alternative This chapter covered the structure of healthcare and ways it is changing. The typical long-term care facility and residents who live there were described. Differentiation between the terms policies and procedures was made and common policies and procedures were discussed. The long-term care survey process and involved agencies were explained. Government-funded payers, Medicare and Medicaid, were differentiated between and payment in long-term care facilities was discussed. The terms culture change and person-directed care were defined and related to the Pioneer Network and The Eden Alternative.