1. 만성질환자 관리 : 재활 세브란스병원 간호부장 김 현 옥

2.  Political Trends  Economic Trends  Demographic Trends  Technological Trends  Societal Trends  Professional Organization Trends Trends Affecting Health Care

3.   Health Care Cost   Health Care Demands  Role of Customers  Available Health Information  Specialization 의료환경 변화

4. Components of Healthcare System  Healthcare payers  Healthcare providers  Healthcare receivers

5. Healthcare Payers( 보험 )  Government Cost based Prospective (DRGs)  Private : Managed Care - Prospective payment

6. Managed Care  Payers demand quality services  Clinical/Critical Pathways  Outcomes Management  Service Coordination   Health care competition

7. Health Care Providers( 병원 )   Length of stay  Management of service utilization  Standardization : Critical/clinical pathways  Outcomes management Ways to manage cost

8. Effects of LOS  Development of healthcare continuum :  Acute care services  Post acute care services  Acute rehabilitation  Sub-acute care  Home care  Outpatients  Long term care

9. Healthcare Continuum Peak wellness No symptoms Symptoms Disease/Injury Disability Screening Early detection Diagnosis Rehabilitation Health Death Preventioin Maintenance Focus Acute care hospitals Acute Rehab.Hosp. Sub-acute care center Home care Outpatient clinics Outpatient Clinics Level of Services Supportive care Long term care center

10. Disease Management  Community based system  Integrated service network  Clinical standards  Physician direction Key concepts

11. Acute Hospital Subacute Long Team care Home care Rehabilitation Subacute Outpatient Home care LTC Home care Primary physician Disease Management: Collaboration Model Medical Management Rehab. effort Health Maintenance End stage

12. Disease Management: Scope of Services Physical DimensionPsychosocial Dimension Social Dimensian Acute careMedical care Rehabilitation Acute/Subacute Medical care ADL functions (Maximize) Adoptation Anxiety Depression Family dynamics Home careMedical care ADL functions (Maximize) Adoptation Depression Anxiety Family dynamics Occupation Recreation Religion Out patientADL functions (maximize) Occupation Long term careMedical care ADL(Maintenance) Quality of life

13. 재활환자 경향  Rehabilitation = Physical Medical Rehabilitation(PMR)  Physical Rehabilitation Medical Rehabilitation

14. Rehabilitation Diagnoses Old Old  Stroke  BI  SCI  Neurology  Arthritis (Osteo)  Arthritis (Rheumatoid)  Amputation  Multi Fracture  Burns New New  Cardiac  Pulmonary  Pain  Fx of LE  Ortho Replacement  Medically complex  Debility

15. Rehabilitation Nursing : Definition  Assist individuals affected by chronic illness or physical disability

16. Goals of Rehabilitation  To achieve individual ’ s greatest potential  To adapt to their disabilities  To work toward productive, independent lives

17. Rehabilitation approach  A Holistic approach to meeting patient needs :  Medical  Educational  Vocational  Environmental  Spiritual  Emotional

18. Rehabilitation practice  Managing complex medical issues  Collaborating with other specialists  Providing patient/family education  Setting goals for optimal independence  Establishing plans of care to maintain optimal wellness

19. Rehabilitation Nurses Roles  Rehabilitation nurse  Rehabilitation education  Rehabilitation clinical specialist  Case manager  Admission liaison (evaluator)  Rehabilitation manager  Administrator  Insurance nurse  Legal nurse

20. Prospective Payment System for Inpatient Rehabilitation Facilities  1997 balanced Budget Refinement Act(BBRA)  A per discharge prospective payment system

21. Goals  To control healthcare cost increase  To redistribute the total amount of payments to rehabilitation facilities  To make payment by rehabilitation patient characteristics  To promote access to rehabilitation facilities

22. Major Elements of the IRF PPS  Patient Assessment Instrument  Patient Classification System  CMG Relative Weights  Payment Rates

23. Payment Assessment Patient Classification CMGs Payment

24. Patient Classification System  Impairment  Functional capabilities  Motor  Cognition  Age  Comorbidities

25. Outcome of DPS   LOS

26. Rehabilitation Management Issues  Preadmission process  Discharge planning  Management of LOS  Cost management  Ancillary service utilization

27. Rehabilitation Outcomes (1990-1998)  Cost  200%  Onset days  30% (early admission to rehab)  FIM change  3%  LOS  20%  Community D/CSame

28. Changes in rehabilitation practice  Goal setting: Short term  Team approach  Service utilization  24hrs Nursing care  Therapy follow-up  Trans-disciplinary approach

29. Cost Management  Re-engineering-Integration  Vertical  Horizontal  Streamlining care process  Less money available  How we deliver  Cost to deliver care to different groups of patient  Where cost can be reduced  Maintain quality and financial viability

30. Cost Management  Care management Clinical pathways  Standardization  Service quality  Information technology  Human resources management  Nursing Shortage/ Flexibility  Cross-training