major orthopedic surgery

HCA 3305, Health Unit Coordination 1

Course Learning Outcomes for Unit II Upon completion of this unit, students should be able to:

2. Describe the various settings in which present-day health care is delivered. 2.1 Summarize the types of services offered to patients at each of the various health care settings

and what type of professional provides those services. 2.2 Describe prominent payment structures for each type of health care setting.

Course/Unit

Learning Outcomes Learning Activity

2.1

Unit Lesson Chapter 2 (2 sections) Website: The Joint Commission (6 case studies) Unit II PowerPoint Presentation

2.2 Unit Lesson Unit II PowerPoint Presentation

Required Unit Resources Chapter 2: The Volatile Healthcare Environment—Read the following sections:

• Marketing Health Care • Healthcare Settings

In order to access the following resource, click the link below. At the Joint Commission website (see link below), take note of the nine types of health care facilities that can achieve accreditation from the Joint Commission. Click on the down arrow next to Accreditation & Certification in the blue bar in the upper left corner. Click on Why Achieve Accreditation to familiarize yourself with the basics of the benefits and the process. Read each of the six case studies (Ambulatory Surgery center, Behavioral Health organization, Home Care organization, Hospitals leverage accreditation, Orthopedic certification, and Nursing Home) by scrolling down to below the subheading Why Achieve Accreditation to explore the benefits of accreditation and learn more about each type of health care setting. The Joint Commission. (n.d.). Health care settings. https://www.jointcommission.org/accreditation-and-

certification/health-care-settings/ Unit Lesson More than ever, the health care industry is comprised of many different settings that provide care to patients under various situations. Care provided can be characterized as inpatient versus outpatient and acute versus subacute. Care can even be rendered in a patient’s home. Most facilities can be described as for-profit or not- for-profit, although some are government or religious institutions (McConnell, 2019). Each setting provides unique employment opportunities for health care workers and a variety of services to consumers. There are also some differences in how services are paid or reimbursed at each setting.

UNIT II STUDY GUIDE Health Care Settings

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Hospitals In 2021, according to the American Hospital Association (AHA, 2021), the United States had 6,090 hospitals operating during fiscal year 2019. Despite the relatively small numbers, hospitals are probably the most well- known health care facilities. General hospitals can care for all types of patients suffering from a wide variety of illnesses, diseases, or injuries. Some hospitals are specialty hospitals, including trauma hospitals, pediatric hospitals, psychiatric hospitals, or hospitals specializing in cancer care (Journal of Hospital & Medical Management, n.d.). Typically, hospitals have emergency departments; inpatient or overnight beds; and ancillary departments such as labs, radiology, and surgical services. Most hospitals employ physicians and midlevel providers such as nurse practitioners or physicians’ assistants, nurses, technicians, and other specialty roles to operate their ancillary departments. In 2019, the breakdown of hospitals included 2,946 not-for-profit hospitals, 1,233 for-profit hospitals, and 1,170 government hospitals (AHA, 2021). At the epicenter, the difference between for-profit and not-for-profit hospitals includes where each gets its money to conduct business, whether they are required to serve the community, and whether they must pay taxes (Masterson, 2017). Nonprofits care for the community despite the ability to pay or insurance status in exchange for not paying taxes. For-profit hospitals typically are owned by corporations with increased cash flow because of investors but have no requirement to care for the community outside of the obligatory stabilization mandated by the Emergency Medical Treatment and Labor Act (EMTALA), and they are subject to paying taxes. Finally, other types of hospitals include government hospitals, academic medical centers, and critical access hospitals. Government hospitals are owned and operated by the federal government that provides the funding to care for specific cohorts of patients such as Native Americans and/or veterans (Gallagher Healthcare, 2018). Academic medical centers are affiliated with a university or medical school and provide education for medical students and other health care professionals while serving the community in which they are located. Critical access hospitals are small hospitals that serve rural communities and receive higher Medicare reimbursement to serve an area that would otherwise not be profitable or sustainable to another type of hospital (Greenwood-Ericksen et al., 2021).

Nonhospital Facilities Moving away from acute, inpatient care, there is a subset of facilities that provide care to patients who do not require care at the hospital level. Examples include inpatient rehabilitation facilities (IRF), skilled nursing facilities (SNF), long-term acute care hospitals (LTACH), and assisted living facilities (ALF). In these types of facilities, a patient’s care is still typically overseen by a physician, but the physician oversight is often much less frequent. IRFs exist to provide intensive rehabilitation to specific types of patients with complex needs to prepare the patient to go home safely (D’Mello, n.d.). Examples of the types of patients served include spinal cord and head injury patients, stroke survivors, and patients recovering from extensive joint surgeries. Patients must use their Medicare, Medicaid, private insurance, or pay privately for care in an IRF. SNFs are sometimes referred to as nursing homes, but this is inaccurate. SNFs provide short-term, skilled care for patients who require daily nursing and therapy care but at a less intense requirement than a hospital or IRF (Medicare, n.d.). Nursing homes are long-term care facilities, typically for elderly or disabled persons who can no longer live independently. The level of care is lower at a nursing home than an SNF (Murphy, 2021). Physicians still oversee patients in SNFs and nursing homes but see patients with less frequency, sometimes only once a month. Typically, SNF care requires a qualifying 3-day hospital stay under Medicare reimbursement, but some SNFs accept commercial insurance and private pay patients. Medicare does not cover custodial care provided at nursing homes, but this level of care is typically covered by Medicaid, long- term care insurance, or private pay (Murphy, 2021).

Home Health Care Sometimes patients prefer or require care in their home. Options include home health care or private duty care. Home health care is periodic care in the patient’s home, ordered and overseen by a physician (Nightingale Homecare, n.d.). Care is categorized as skilled or custodial and covered under Medicare, Medicaid, and most private insurance plans. To be covered under a payer’s plan, the patient must be homebound, meaning leaving the home to receive care would be too taxing and/or dangerous for a patient. Alternatively, private duty care is custodial, not overseen by a physician, and is only paid for by private

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payments by the individual or family seeking the care. Skilled home care is provided by trained professionals, whereas private duty care may be provided by unskilled workers (Nightingale Homecare, n.d.). Hospice Hospice is a unique health care service that provides care for those suffering from incurable diseases or terminal illnesses (McConnell, 2019). Hospice care can be provided within a hospital, a freestanding center, or a patient’s home. Hospice services include a wide array of services provided by physicians, nurses, and other professionals aimed at palliating or lessening suffering by controlling symptoms at the end of life. Hospice is covered by Medicare, Medicaid, and most commercial insurances. Many hospice providers have grants or other types of programs to provide care free of charge or at a significantly reduced rate for qualifying patients who are uninsured (American Cancer Society, 2019).

Ambulatory Care Another range of health care services are provided in the ambulatory care setting, such as ambulatory surgery centers (ASC), urgent care centers (UCC), freestanding emergency departments (FSED), and physicians’ offices. ASCs are facilities where more minor surgeries are performed that do not require admission to a hospital (Ambulatory Surgery Center Association, n.d.). Witiw et al. (2020) indicate ASCs are more efficient and cost effective than hospitals for some surgical procedures. By 2010, ASCs had increased by more than 60% in the United States. UCCs provide immediate treatment for more minor illnesses and injuries that do not necessarily necessitate care in an emergency department. According to McNeely (2012), UCCs can be traced back to the early 1970s. The hallmark of urgent care includes extended coverage hours, no appointments necessary, and lower costs than those associated with emergency departments. By comparison, FSEDs can be associated with hospitals or owned and operated by physicians or nonphysician capitalists (Ayers, 2021). However, their hallmark is that they are geographically situated separate from a hospital but aim to provide similar care to what can be provided at a hospital emergency department. However, critics argue that UCCs are not really similar to hospitals because they are limited by factors such as the ability to admit patients overnight or have them seen by specialists.

Outpatient Care Finally, patients can receive outpatient care at any number of physician offices. Typically, this care is either primary care or ongoing care for more chronic conditions. Outpatient care is typically seen as first-contact care and theoretically is the backbone of a health care system. However, Levine et al. (2019) report that of all the people who reported not using primary care or outpatient physician services, 67% had insurance but still chose not to engage with the health care system for preventative or chronic care needs. Despite this trend, health centers are proliferating and include collections of outpatient medical practices and a wide variety of ancillary services within one geographic location to serve patients (McConnell, 2019). Payment for services received at ASCs, UCCs, FSEDs, and in physicians’ offices is typically on a fee-for- service basis. Most of these ambulatory care centers accept Medicare, Medicaid, or commercial insurance. Most often, Medicare reimburses at fixed rates, where commercial insurances reimburse at negotiated contract rates (Mathews, 2015).

Conclusion Historically, patients went to hospitals when they were sick or injured; however, mainly due to pressures to reduce health care related costs, care is shifting to other, less-acute levels of care when appropriate. As a rising health care leader, one can expect to interact with many different types of health care settings in order to meet the needs of patients. Each setting provides somewhat unique services, are typically governed by specific rules and regulations, and accept payment in distinctive ways.

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References Ambulatory Surgery Center Association. (n.d.). What are ambulatory surgery centers?

https://www.inova.org/upload/docs/Healthcare%20Services/Surgery/ambulatory-surgery-centers- brochure.pdf

American Cancer Society. (2019, May 10). Hospice care.

https://www.cancer.org/content/dam/CRC/PDF/Public/342.00.pdf American Hospital Association. (2021). Fast facts on U.S. hospitals, 2021. https://www.aha.org/statistics/fast-

facts-us- hospitals#:~:text=Other%202%20Hospitals.%20116%20Total%20Staffed%20Beds%20in,Intensive% 20Care%205%20Beds%20in%20Community%20Hospitals.%2015%2C160

Ayers, A. A. (2021). Understanding the freestanding emergency department phenomenon. The Journal of

Urgent Care Medicine. https://www.jucm.com/understanding-the-freestanding-emergency- department-phenomenon/

D’Mello, P. (n.d.). What is an inpatient rehabilitation facility? Repisodic Blog.

https://followupcare.org/blog/what-is-inpatient-rehabilitation-facility Gallagher Healthcare. (2018, March 22). What are the different types of hospitals?

https://www.gallaghermalpractice.com/blog/post/what-are-the-different-types-of- hospitals#:~:text=Sometimes%20referred%20to%20as%20government%20hospitals%2C%20federal %20hospitals,such%20as%20Native%20Americans%20and%20Veterans.%20For- Profit%20Hospitals

Greenwood-Ericksen, M., Kamdar, N., Lin, P., George, N., Myaskovsky, L., Crandall, C., Mohr, N. M., &

Kocher, K. E. (2021, November 19). Association of rural and critical access hospital status with patient outcomes after emergency department visits among Medicare beneficiaries. JAMA Network Open, 4(11), Article e2134980. http://dx.doi.org/10.1001/jamanetworkopen.2021.34980

Journal of Hospital & Medical Management. (n.d.). Hospitals. https://www.imedpub.com/scholarly/hospitals-

journals-articles-ppts- list.php#:~:text=Hospitals%20are%20health%20care%20institutions%20providing%20patient%20trea tment,type%20since%20it%20is%20provided%20with%20emergency%20department

Levine, D. M., Landon, B. E., & Lindner, J. A. (2019, January 28). Quality and experiences of outpatient care

in the United States for adults with or without primary. JAMA Internal Medicine, 179(3), 363–372. http://dx.doi.org/10.1001/jamainternmed.2018.6716

Masterson, L. (2017, May 25). Nonprofit, for-profit hospitals play different roles but see similar financial

struggles. Healthcare Dive. https://www.healthcaredive.com/news/nonprofit-for-profit-hospitals-play- different-roles-but-see-similar-financ/442425/

Mathews, A. W. (2015, October 19). Outpatient medical care prices are rising, study shows. The Wall Street

Journal. https://www.wsj.com/articles/new-study-on-hospitals-acquiring-doctor-practices-seen-fueling- debate-1445266894

McConnell, C. R. (2019). The effective health care supervisor (9th ed.). Jones & Bartlett Learning.

https://bookshelf.vitalsource.com/#/books/9781284166194 McNeely, S. (2012, Summer). Urgent care centers: An overview. American Journal of Clinical Medicine, 9(2),

80–81. https://www.aapsus.org/wp-content/uploads/ucc80.pdf Medicare. (n.d.) Skilled nursing facility (SNF) care. U.S. Centers for Medicare and Medicaid Services.

https://www.medicare.gov/coverage/skilled-nursing-facility-snf-care

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Murphy, B. (2021, October 15). The difference between nursing homes and skilled nursing facilities. Hebrew SeniorLife. https://www.hebrewseniorlife.org/blog/difference-between-nursing-homes-and-skilled- nursing-facilities

Nightingale Homecare. (n.d.). Understanding home health care and private duty services.

https://www.ngcare.com/wp-content/uploads/2017/03/home-health-care-vs-private-duty-6-1.pdf Witiw, C. D., Wilson, J. R., Fehlings, M. G., & Traynelis, V. C. (2020). Ambulatory surgery centers: Improving

quality of operative spine care? Global Spine Journal, 10(1), 29S–35S. http://dx.doi.org/10.1177/2192568219849391