Applied Science
Lucy Bell
Ch.7powerpoint.pptxChapter 7
Outpatient Services and Primary Care
Introduction
Health care delivery has increasingly moved away from expensive acute care hospitals.
Hospitals have been major players in outpatient services as the range of services has expanded.
Solo practices have consolidated to cope with competition.
Government agencies have sponsored limited outpatient services to meet the needs of underserved populations.
2
What Is Outpatient Care? (1 of 2)
The terms “outpatient” and “ambulatory” are used interchangeably.
Ambulatory care: Diagnostic and therapeutic services and treatment for the walking patient.
Outpatient service: Any health care service that does not require an overnight stay in a health care institution.
What Is Outpatient Care? (2 of 2)
Ambulatory care:
Care rendered to patients who come to the:
Physician’s office
Clinics
Outpatient surgery
Mobile diagnostic units and home health
Take services to patients
Scope of Outpatient Services (1 of 3)
Hospital inpatient services continue to decline.
Executives see outpatient care as an essential, no longer supplemental, service line.
Intensified competition between hospitals and community-based providers for patients using outpatient medical services.
Scope of Outpatient Services (2 of 3)
Reasons for growth
Reimbursement
Financial incentives to reimburse for outpatient care
Patients favoring outpatient services
Development of new technology
Less invasive procedures; surgical procedures less traumatic
Shorter-acting anesthetics
Faster recovery time
Scope of Outpatient Services (3 of 3)
Reasons for growth (cont’d)
Utilization controls
Inpatient hospital stay has been strongly discouraged by various payers.
Prior authorization (precertification) required, minimizing length of stay.
Social factors
Patients have strong preference for receiving health care in home and community-based settings, as it gives people a sense of independence and control over their lives.
Important for quality of life.
Outpatient Care Settings and Methods of Delivery (1 of 18)
Private practice
Office-based physicians
Backbone of ambulatory care
Vast majority of primary care services
Limited examination and testing
Outpatient Care Settings and Methods of Delivery (2 of 18)
Private practice (cont’d)
Visits are short in duration.
Solo practices have merged into groups due to:
Uncertainties of the health care delivery system
Competition from large health organizations
High cost of establishing a new practice
Complexity of billings and collections
Increased external controls over private practice
Outpatient Care Settings and Methods of Delivery (3 of 18)
Hospital-based outpatient services
Prominent particularly in inner-city areas
Community’s safety net, providing primary care to the indigent and uninsured
A key source of profits for hospitals
Outpatient Care Settings and Methods of Delivery (4 of 18)
Hospital-based outpatient services (cont’d)
Main types:
Clinical (typically for uninsured or research)
Surgical (same day surgery)
Home health (postacute care and rehabilitation)
Women’s health
Traditional emergency
Outpatient Care Settings and Methods of Delivery (5 of 18)
Free-standing facilities
Walk-in clinics
Ambulatory care from basic primary to urgent care
Nonroutine, episodic basis
Urgent care centers
Accept patients without appointments
Wide range of routine services
First come, first served
Outpatient Care Settings and Methods of Delivery (6 of 18)
Free-standing facilities (cont.)
Surgicenters
Freestanding, independent of hospitals
Full range of services for surgeries
Outpatient, no overnight
Outpatient Care Settings and Methods of Delivery (7 of 18)
Mobile medical, diagnostic, and screening service
Mobile health units
Transported to patients (i.e., ambulances with emergency medical technicians)
Mobile diagnostic care unit
Mammography
Magnetic resonance imaging
Outpatient Care Settings and Methods of Delivery (8 of 18)
Telephone or Internet triage
Provide expert opinion and advice to the patient, especially during hours when a physician’s office is usually closed
Nurses have:
Access to patient records
Guidance using protocols
Consults with physicians
© 2010 Jones and Bartlett Publishers
Outpatient Care Settings and Methods of Delivery (9 of 18)
Home care
Service brought into the home
Nursing care
Change dressings
Medication monitoring
Bathing
Short-term rehabilitation (PT, OT, ST)
Homemaker services (meal prep, shopping, transportation, medical equipment, chores)
Durable medical equipment (wheelchairs, oxygen, beds, walkers, commodes)
Outpatient Care Settings and Methods of Delivery (10 of 18)
Home care (cont’d)
Alternative to institutionalization
Maintaining people in the least restrictive environment possible
Outpatient Care Settings and Methods of Delivery (11 of 18)
Hospice care
Provides services for the terminally ill with life expectancy of 6 months or less
Provides services that address the special needs of dying persons and their families
A method of care, not a location
Outpatient Care Settings and Methods of Delivery (12 of 18)
Hospice care (cont’d)
Services include:
Medical, psychological, and social services provided in a holistic context
Access to supplies
Two areas of emphasis
Palliation (pain management)
Psychosocial and spiritual support
Outpatient Care Settings and Methods of Delivery (13 of 18)
Outpatient long-term care services
Nursing homes
Case management
Coordination and referral
Find most appropriate care
Adult day care
Complements informal care provided at home at a center during the day
Outpatient Care Settings and Methods of Delivery (14 of 18)
Public health services
Typically provided by local health departments
Services include:
Well-baby care
Venereal disease clinics
Family planning services
Screening and treatment for tuberculosis
Outpatient mental health
Outpatient Care Settings and Methods of Delivery (15 of 18)
Community health centers
Authorized in the 1960s to serve the medically underserved
Operate under the Bureau of Primary Health Care, U.S. Public Health Service, U.S. Department of Health and Human Services
Outpatient Care Settings and Methods of Delivery (16 of 18)
Free clinics
Modeled after the 19th-century dispensary
Provide general ambulatory care to the poor
Services provided at little to no charge
Not directly supported or operated by the government or the health department
Services delivered by trained volunteers
Outpatient Care Settings and Methods of Delivery (17 of 18)
Alternative medicine clinics
Complementary or alternative medicine
Not endorsed by Western medicine
Nontraditional
Outpatient Care Settings and Methods of Delivery (18 of 18)
Alternative medicine clinics (cont’d)
Treatments include:
Homeopathy
Herbal formulas
Products as preventive and treatment agents
Acupuncture
Meditation
Yoga
Biofeedback
Spiritual guidance
Prayer
Chiropractic
Primary Care (1 of 3)
Conceptual foundation for outpatient health services.
Not all outpatient care is primary care.
Focuses on the type or level of services:
Prevention
Diagnosis
Therapeutic services
Health education
Counseling
Minor surgery
An approach to providing health care, not a set of specific services.
Primary Care (2 of 3)
Secondary care
Usually short-term
Sporadic consultation from a specialist
Includes hospitalization
Routine surgery
Rehabilitation
Primary Care (3 of 3)
Tertiary care
Most complex level of care, primarily for conditions that are uncommon
Usually institution based, often at large teaching hospitals
Highly specialized
Technology driven
May be for long-term care (i.e., trauma, burn treatment, NICU, transplants, open heart surgery)
WHO’s Definition of Primary Health Care
Essential health care based on scientific methods
Universally accessible and acceptable
Affordable cost to maintain health at every developmental stage
The first level of contact
Bringing health care as close as possible to where people live and work
First element of a continuing health care process
Institute of Medicine on the Future of Primary Care
Primary care should be:
The provision of integrated, accessible health care services by clinicians who address health care needs and develop a partnership with patients, the family, and community.
Domains of Primary Care (1 of 11)
Point of entry
Community based
Coordination of care
Essential care
Integrated care
Accountability
Domains of Primary Care (2 of 11)
Point of entry
The first contact a patient makes with the delivery system, primarily through access to primary care
Domains of Primary Care (3 of 11)
Point of entry (cont’d)
Role of a gatekeeper
Patients cannot see a specialist or be admitted without a physician’s referral.
This protects patients from unnecessary procedures and overtreatment.
Goals
Bring point of entry as close to the population as possible
Community based
Convenient
Accessible
Domains of Primary Care (4 of 11)
Community based
Characterized by convenience and accessibility.
Must be basic, routine, and inexpensive in order to be widely available to urban, suburban, and rural communities.
Domains of Primary Care (5 of 11)
Coordination of care
Coordination of delivery of health services between the patient and the myriad of components of the system.
Refer patients to sources of specialized care.
Give advice regarding various diagnoses and therapies.
Ensure continuity and comprehensiveness.
Discuss treatment options.
Provide continuing care of chronic conditions.
Domains of Primary Care (6 of 11)
Figure 7.1 Coordination Role of Primary Care in Health Delivery
Domains of Primary Care (7 of 11)
Essential care
Countries with health systems oriented toward primary care:
Achieve better health levels
Have higher satisfaction with health services
Have lower expenditures in the delivery of health
Countries with weak primary care infrastructures incur:
Poorer health outcomes
Higher health care costs
Domains of Primary Care (8 of 11)
Essential care (cont’d)
Goals:
To optimize population health
For disparities to be minimized
To ensure equal access
In the United States:
Public and private financing have created a fragmented system.
Primary care does not form the organizing hub for continuous and coordinated health services.
Domains of Primary Care (9 of 11)
Integrated
Comprehensive: Addresses health problems at any stage of a patient’s life cycle
Coordinated: Combines health services to best meet the patient’s needs
Continuous services: Care over time by a single provider or a team of health care professionals who provide a seamless process of care
Domains of Primary Care (10 of 11)
Accountability
Clinicians and patients are both accountable.
The clinical system is accountable for:
Providing quality care
Producing patient satisfaction
Using resources efficiently
Behaving in an ethical manner
Patients are responsible for:
Their own health to the extent of influencing it
Being judicious in the use of resources
Domains of Primary Care (11 of 11)
Accountability (cont’d)
Partnership between a patient and a clinician.
Mutual trust, respect, and responsibility are the hallmarks of this partnership.
Community-Oriented Primary Care (1 of 2)
Incorporates primary care with a population-based approach to identify and address community health problems
Biopsychosocial paradigm
Emphasizes need and health priorities of both the population and the individual
Community-Oriented Primary Care (2 of 2)
Main challenge:
Determining best means to bring together individual health needs in the larger context of community health needs
Obstacles to adopting the biopsychosocial paradigm
Workforce shortages
Financial incentives
Primary Care Around the World
Dual challenges of a shrinking medical workforce and increasing health care demands
Impetus for delivery of team-based primary care
Models for implementing primary care teams:
Canada
Australia
Effectiveness of Primary Care
Preventive interventions should be carried out in primary care.
Continuity of care with one provider is positively associated with primary preventive care.
The likelihood that disadvantaged children will be brought for regular health visits is greater with a good primary provider.
Early detection of breast cancer is enhanced with an adequate supply of primary care physicians.
Hospitalizations and Use of Emergency Care
Evidence exists that hospitalizations for ambulatory care–sensitive conditions are less frequent when primary care is strong.
Costs of Care
When primary care is stronger and when the primary care physician-to-population ratio is higher, total health care costs are much lower than in areas where there are fewer physicians.
Morbidity
Higher primary care physician supply has been associated with:
Reduction in low-birthweight infants
Decreased infant mortality
Better-controlled hypertension
Mortality
The supply of primary care physicians has been shown to have a direct influence on:
Life expectancy
Stroke
Postnatal mortality
Total mortality
The Medical Home Strategy
A model for the provision and coordination of primary care.
Chronic care model with multidisciplinary practice-based teams.
Usual source of care is primary care provider.
Improves patient health outcomes and satisfaction, reduces medical errors, and reduces costs without compromising quality of care.
Use of Information Technology in Primary Care
Can help enhance the delivery of high-quality care and better patient outcomes
HITECH Act (2009)
ACA strategic plan
Barriers to effective use
Types of health IT applications generally used
Assessment of Community Health Centers
Quality of care
Access to care
Cost-effectiveness
Affordable Care Act and Community Health Center Fund
Challenges to CHCs
Inadequate funding
Overwhelming workload for physicians
Conclusion
Outpatient services transcend basic and routine primary care services.
General medical and surgical interventions are provided in ambulatory care settings.
Primary care is:
The point of entry into the health services system
Where health care delivery is organized
Essential
