Health Care Reform. FAQs and Frequently Used Terms

Transcription

1 Health Care Reform FAQs and Frequently Used Terms Page 0

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3 FREQUENTLY ASKED QUESTIONS Q: What is Healthcare Reform? A: Healthcare Reform is a national approach to improving both access and quality of care in this nation. On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act of Health Care Reform is the largest insurance expansion since Medicare and Medicaid were enacted in Q: Why is Healthcare Reform needed? A: As the rate of uninsured and underinsured population increases, intense strain is placed on America s healthcare delivery system to provide coverage while sustaining costs and quality. Healthcare Reform attempts to solve some of the many problems with America s health care delivery system, including the impact of having 46 million uninsured Americans, escalating healthcare costs, and limited access to quality health care. Q: What does Healthcare Reform do? A: Healthcare Reform: Expands Medicaid to allow more people at the lowest income levels to qualify for coverage. Encourages employers to offer health insurance. Provides credits to purchase private health insurance for Americans who do not qualify for Medicaid. Streamlines the purchase of health insurance through the establishment of the Health Insurance Exchange. Imposes protections to guard against unreasonable rate increases. Encourages primary and preventive care. Requires most Americans to purchase health insurance. Q: How will Healthcare Reform impact my nursing home? A: There are many changes in how payments are given to nursing homes. Intense pressure is being placed on all healthcare facilities to reduce cost and to enhance quality and care without additional financial resources. This ultimately means that nursing home teams will need to work, coordinate and communicate differently to meet the new challenges and demands of Healthcare Reform. Page 2

4 Q: How can I prepare for Healthcare Reform? A: Healthcare reform requires that healthcare organizations put residents and patients at the center of care. The most successful nursing homes will be those where staff at all levels are engaged in person-centered care activities where: Activities are coordinated through teams that are held accountable for outcomes, Communication occurs within, beyond and across the healthcare continuum to ensure continuity of care, Healthcare workers are flexible and adaptable to change, and utilize learning and technology to help them in the process, Leadership and collaboration occur at every level of the organization, Staff at are levels are continuously seeking to learn and enhance their skill sets Q: What can I do if I want to learn more about Healthcare Reform? A: There is a lot of information available on health care reform. Healthcare Reform is a multi-year plan with specific changes happening during different years. Thus, there is always something new to learn. Here are just a few suggestions: Have conversations within your nursing home about it. Many nursing homes have already started preparing find out how you can get involved! Your local person-centered care committee, delegate meetings, staff meetings and town halls are just a few places where this conversation can be held. Watch the news and browse the web. Keep yourself informed. Here are a few sources for you to get started: o o o o Kaiser Family Foundation Summary of New Health Reform Law Timeline of Changes Health Reform.gov o New York State Medicaid Redesign Team Page 3

5 KEY TERMS Page 4

6 30 DAY READMISSION POLICY: CMS is targeting readmissions to the hospital within 30 days of discharge as a probable marker for quality of care. CMS defines a readmission as a hospital admission 30 days within the date of discharge from the initial hospital. If such an event occurs, the hospital would be subject to a payment penalty. ACCESS: The ability to obtain needed medical care. Access to care is often affected by the availability of insurance, the cost of care and the geographic location of providers. ACCOUNTABLE CARE ORGANIZATION: An ACO is a local health care organization and a related set of providers (at a minimum, primary care physicians, specialists, and hospitals) that can be held accountable for the cost and quality of care delivered to a defined patient population. The goal of the ACO is to deliver coordinated and efficient care. ACOs that achieve quality and cost targets will receive some sort of financial bonus, and under some approaches, those that fail will be subject to a financial penalty. CAPITATION: A method of paying for health care services under which providers receive a set payment for each person instead of receiving payment based on the number of services provided or the costs of the services rendered. These payments can be adjusted based on the demographic characteristics, such as age and gender, or the expected costs of the members. CASE MIX INDEX: A number which represents an average of all of a facility s PRI scores at a moment in time. A higher score generally means that residents require a great deal of care, and therefore, the facility receives higher reimbursement. CASE MIX: The distribution of patients into categories reflecting differences in severity of illness or resource consumption. CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS): The federal agency that runs the Medicare program that finances many nursing homes through a state-specific reimbursement system. CHRONIC CARE MANAGEMENT: The coordination of both health care and supportive services to improve health status of patients with chronic conditions, such as diabetes and asthma. The goals of these programs are to improve the quality of health care provided to these patients and to reduce costs. Page 5

7 COMMUNITY HEALTH WORKER: Community health workers are lay members of communities who work with the local health care system and usually share ethnicity, language, socioeconomic status and life experiences with the community members they serve. They have been identified by many titles such as community health advisors, lay health advocates, outreach educators, community health representatives, peer health promoters, and peer health educators. CHWs offer interpretation and translation services, provide culturally appropriate health education and information, assist people in receiving the care they need, give informal counseling and guidance on health behaviors, advocate for individual and community health needs, and provide some direct services such as first aid and blood pressure screening. DECENTRALIZED DINING: A process of food service delivery where central tray lines are removed and food is distributed in local neighborhoods or communities using mobile carts or satellite steam tables. Food may be prepared in a central location or on the unit, but is plated in a restaurant buffet-style fashion. This model of food service often leads to less food waste and provides more choice for residents when dining. FEDERALLY QUALIFIED HEALTH CENTER (FQHC): FQHCs are community-based and patient-directed organizations that provide comprehensive primary care and preventive care, to populations with limited access to health care, regardless of ability to pay. These include low income populations, the uninsured, those with limited English proficiency, migrant and seasonal farm workers, individuals and families experiencing homelessness, and those living in public housing. In return for serving all patients regardless of ability to pay, FQHCs receive consideration from the Federal government in the form of a cash grant, cost-based reimbursement for their Medicaid patients, and free malpractice coverage under the Federal Tort Claims Act (FTCA). FIVE STAR SYSTEM/NURSING HOME COMPARE: A web-based resource offered through CMS to help consumers, their families, and caregivers compare nursing homes more easily using a Five-Star Quality Rating System (similar to hotel or restaurant reviews). The rating system is based on three sources of data: Health Inspections, Staffing, and Quality Measures. GREEN HOUSE: An approach to person-centered care involving both physical plant and organizational redesign. Each Green House residence is designed to be a home for 6 to 10 elders, blending architecturally with neighboring homes. Green Houses contain intimate spaces with warm interior designs and staff that help residents receive a high level of personalized and professional medical care and support with daily living. All residents of the Green House have private rooms or units with a private bathroom. HEALTH CARE ACQUIRED CONDITIONS: Conditions that are acquired during hospitalization that may be potentially preventable such as infections, deep vein thrombosis, or falls with injury. The additional treatments and increased length of stay resulting from these conditions will not be reimbursed by insurers. Page 6

8 A general term used to describe health care policy changes or creation. The most recent policy change targeting Health Care Reform is the Patient Protection and Affordable Care Act, signed into law by President Barack Obama on March 23, This Act seeks to: HEALTH CARE REFORM: Broaden the population that receives health care coverage through either public sector insurance programs or private sector insurance companies Expand the array of health care providers consumers may choose among Improve the access to health care specialists Improve the quality of health care Give more care to citizens Decrease the cost of health care A term used to describe the use of computers and technology in healthcare settings that are designed to lower health care spending and to improve efficiency, quality and safety of medical care delivery. According to the Bureau of Labor Statistics, demand for health information professionals will increase by 20 percent through Some examples of Healthcare Information Technology include: HEALTH INFORMATION TECHNOLOGY (HIT): Automatic dispensing machines (ADM) or automated drug cabinets are computerized drug storage and dispensing devices used in lieu of or in conjunction with central pharmacies. The ADM provides proper storage, inventory control and security for pharmaceuticals at the point of care. Electronic Medical Records (EMRs), an adapted version of the patient record in an electronic format primarily intended for health care providers and stored within a given institution or organization such as hospital or health delivery system. Bar Coding at Medication Administration (BarA) is a software application that utilizes barcode technologies in combination with the internet to transmit information to a centralized computer to improve the accuracy of the medication administration at the bedside or at other points of care. Clinical Decision Support system (CDSS or CDS) is an interactive decision support system (DSS) Computer Software, which is designed to assist physicians and other health professionals with decision making tasks, as determining diagnosis of patient data. Computerized Physician/provider Order Entry (CPOE) is defined as the computer system that allows direct entry of medical orders by the person with the licensure and privileges to do so. Electronic Health Records (EHRs), which have a similar structure to EMRs, but are shared cross-institutionally to link data from various providers. Electronic Medication Administration (EMAR). A point-of-care process utilizing bar code reading technology to monitor the bedside administration of medications. The overriding benefit of implementing an emar system in a hospital is to ensure patient safety and reduce medication administration error. Personal Health Records (PHRs) that allow individuals to collect, view, manage, or share their health information electronically. Page 7

9 HOUSEHOLD: Households consist of small groups of residents (12-20) where each household is designed with amenities to resemble a traditional family home (i.e.-kitchen, dining room, living room, laundry, etc). ISLAND PEER REVIEW ORGANIZATION (IPRO): MEDICAL HOME MODEL: A federally designated QIO organization that works specifically with long-term care organizations in NY State. QIOs often collect data and make specific recommendations around care delivery and work on any quality improvement initiatives set forth by CMS. An approach to providing comprehensive primary care that facilitates partnerships between individual patients and their personal providers. Medical Home models provide accessible, continuous, coordinated and comprehensive patient-centered care. A Medical Home, is managed centrally by a primary care physician, with the active involvement of coordinated, non-physician staff. MEDICARE: Enacted in 1965 under Title XVII of the Social Security Act, Medicare is a federal entitlement program that provides health insurance coverage to 45 million people, including people age 65 and older, and younger people with permanent disabilities, end state renal disease, and Lou Gehrig's disease. MINIMUM DATA SET (MDS): A federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing facilities. The entire process, called the Resident Assessment Instrument (RAI), provides a comprehensive assessment of each resident's functional capabilities and helps nursing facility staff identify health problems. MDS assessments are required for residents on admission to the nursing facility and then periodically, within specific guidelines and time frames. In most cases, participants in the assessment process are licensed health care professionals employed by the nursing facility, sometimes referred to as the MDS or RAI Coordinator. MDS information is transmitted electronically by nursing facilities to the MDS database in their respective states. MDS information from the state databases is captured into the national MDS database at the Centers for Medicare and Medicaid (CMS). The information filled out on the MDS determines the Resource Utilization Group (RUG) category, which ultimately determines the home s reimbursement rate. The MDS data also feeds into the facility s quality indicator and quality measure reports, some of which are publicly reported and some of which are used by surveyors during the survey process. NEIGHBORHOODS: Also sometimes referred to as clusters of households, share common community areas reflective of a neighborhood in the community at large such as libraries, beauty/barber shops, community rooms, courtyards, cafes and snack bars, and shared staff spaces (Calkins, 2003). Some units are often renamed as Neighborhoods as well. PATIENT REVIEW INSTRUMENT: A form that briefly summarizes a resident s medical, psycho-social and physical needs. This form is required for all newly-admitted residents and is updated on a regular basis. Data from this form is used to determine a resident s RUGS category and is directly connected to a facility s reimbursement rate. Page 8

10 PAY FOR PERFORMANCE: A health care payment system in which providers receive incentives for meeting or exceeding quality, and sometimes cost, benchmarks. Some systems also penalize providers who do not meet established benchmarks. The goal of pay for performance programs is to improve the quality of care over time. PERSON-CENTERED CARE (PCC): Also referred to as culture change, is a model of care delivery that returns control to residents of nursing homes and those who work closest with them. It seeks to create a culture where choice, dignity, empowerment, and quality of life are maximized. Often, this involves transforming traditional nursing homes to reflect how residents would live if they were truly at home. PRE-EXISTING CONDITION EXCLUSIONS: A pre-existing condition is a health problem that existed before you apply for a health insurance policy or enroll in a new health plan. One of the hallmarks of the Patient Protection and Affordable Care Act signed into law in March 2010 is the elimination of pre-existing condition requirements imposed by health plans. Effective September 2010, children (below age 19) with pre-existing conditions may not be denied access to their parents' health plan and insurance companies will no longer be allowed to insure a child, but exclude treatments for that child's pre-existing condition. Starting in 2014, this provision will apply to adults as well. PREVENTATIVE CARE: Health care that emphasizes the early detection and treatment of diseases. The focus on prevention is intended to keep people healthier for longer, thus reducing health care costs over the long term. QUALITY IMPROVEMENT ORGANIZATIONS (QIOS): QIOs monitor the appropriateness, effectiveness, and quality of care provided to Medicare beneficiaries. They are private contractor extensions of the federal government that work under the auspices of the U.S. Centers for Medicare and Medicaid Services (CMS). QIOs provide support and training to health care providers and staff. QUALITY INDICATOR: A set of clinical indicators based off the MDS that are used to track quality of care. Indicators include: Accidents, Behavior/Emotional Patterns, Clinical Management, Cognitive Patterns, Elimination/Incontinence, Infection Control, Nutrition/Eating, Physical Functioning, Psychotropic Drug Use, Quality of Life, and Skin Care. QUALITY INDICTOR SURVEY (QIS): The Quality Indicator Survey (QIS) is a computer-assisted long-term care survey process that was developed under Centers for Medicare & Medicaid Services (CMS). The primary goal is to improve consistency and accuracy of quality of care and quality of life problem identification by using structured investigation. The QIS was designed as a staged process for use by surveyors to systematically review CMS/DOH requirements and objectively investigate all triggered regulatory areas. Page 9

11 QUALITY MEASURE: A specific numerical value of a Quality Indicator. QUALITY OF LIFE: A complex concept reflecting the characteristics of an individual s relationship to his social and physical environment. Quality of life has both residents rights and physical environment dimensions. It reflects the relationship between the resident and the physical and human environment in which he or she lives. READMISSION OF PATIENTS WITHIN 30 DAYS OF DISCHARGE: Close to one in five (18%) Medicare patients return to the hospital within 30 days of discharge. Overall, readmissions cost Medicare an estimated $17 billion yearly. Of this total, about $12 billion are believed to be avoidable cases. Hospitals not fully reimbursed by CMS for readmissions. RESOURCE UTILIZATION GROUP (RUGS): An approach to determining reimbursement rates based on the amount of resources (rehabilitation, therapy, staff time, medication, supplies, etc.) as indicated on a resident s PRI. There are different groups, each of which generates a different reimbursement rate. Nursing homes moving toward PCC seek to provide more autonomy and individualized care and move away from institutionalized/medical care delivery models. This may take the form of renovated buildings into households with a full service kitchen, living room, dining room and private rooms, spa-like bathing areas, food cooked-to-order, accessible laundry areas and outdoor areas, as well as more comfortable/communal living areas. SERIOUS ADVERSE EVENT: Any medical occurrence that results in death, is life threatening, requires inpatient hospitalization or prolongation of existing hospitalization, or results in persistent or significant disability/incapacity. VALUE BASED PURCHASING: In the health care delivery system, value based purchasing (VBP) is a payment methodology that rewards quality of care through payment incentives and transparency. In health care, value can be broadly considered to be a function of quality, efficiency, safety, and cost. In VBP, providers are held accountable for the quality and cost of the health care services they provided by a system of rewards and consequences, conditional upon achieving pre-specified performance measures. Top 20 percent of nursing homes will qualify for incentives derived from savings due to avoidable hospitalizations and SNF stays. Page 10