Need ONE Response Per Each Discussion Total 2Responses. Attached Are The Discussions And Rubric Please Follow Them. Posts Will Be A Minimum Of 100 Words, APA Format.One Reference Per Each Discussion

Racquel Baptista (response to question 2)

The organized health care delivery system known as managed care was borne of a need to provide safe, quality, efficient care while managing costs and utilization, as well as improving patient outcomes and overall wellness. Contrary to fee for service where providers are essentially paid for sick care, managed care incentivizes well care and prevention. Managed care attempts to control spending through care coordination (Enthoven et al, 2019). The nurse’s role in ensuring patient’s needs and benchmarks such as HEDIS measures are met is to drive the quality care of the patient. Coordinating the care of the patient means addressing any barriers to self-care, promoting preventive care, enhancing patient’s knowledge of their disease process, implementing patient centered care plans, and ensuring follow up and understanding of instructions after discharge; all while being mindful of waste, abuse and duplication of services.

In order to meet pay for performance benchmarks, my organization offers monetary incentives for meeting specific goals such as greater than 80 percent of the patient panel with a hemoglobin A1C less than 9 or blood pressure less than 140/90 or BMI less than 30. We use an interdisciplinary approach to empower and educate patients on their specific disease processes and management of those chronic diseases. Some members of the interdisciplinary team include the nurse, doctor or nurse practitioner, clinical pharmacist, social worker and nutritionist. I have the benefit of working for an organization with numerous programs in place to assist patients with both social and medical needs. By addressing social determinants of health, we can improve patient outcomes. Patients have easy access to all members of their care team as well as the home telehealth team for home monitoring of vital signs and early intervention. We are able to offer vocational rehab, housing assistance, weight loss and exercise programs, and even health coaching if needed. As the nurse, it is our job to recognize the patients needs and help them to meet those needs by utilizing available resources.

Reference

Enthoven, A., Fuchs, V. R., & Shortell, S. M. (2019). To Control Costs Expand Managed Care and Managed Competition. JAMA: Journal of the American Medical Association, 322(21), 2075–2076. https://doi-org.ju.idm.oclc.org/10.1001/jama.2019.17147

Tanya Molina (response to question 2)

Nursing’s role to managed care and its implications to care are indicative as they can contribute significantly to the goal of controlling and lowering medical costs by continuing to provide high-quality patient care and access to healthcare, and thoroughly educating the patients on their health condition(s) and prevention of worsening health conditions. Other ways nursing has a role in managed care would be to advocate for the patients and strive to work well in parallel with the physicians and interdisciplinary teams to coordinate good patient care, keeping in mind to achieve the goal of good patient outcomes to prevent the patient from seeking healthcare frequently at the hospital and or their primary cares office. In Toseef et al (2020) study it states that managed care plans have goals of reducing healthcare costs and utilizing the PCP as the gatekeeper by providing preventative treatments and services and dampening the overuse of resources in healthcare. Lack of quality health care was indicated by estimates of 13% to 27% of ED visits from patients that could have been prevented, if they sought management and treatment of their conditions in ambulatory centers such as physician offices, urgent care centers, and clinics. (Toseef et al., 2020).

At the facility I am employed, they constantly and consistently strive for quality improvement by means of developing new positive processes, the use of high technology, and sophisticated equipment that perform procedures successfully the first time, and provide high-quality patient care, which allows them to participate and meet the pay for performance benchmarks. Their main goal is to keep their medical costs low, deliver safe and effective healthcare resulting in the best outcome for their patients, and reducing patient readmissions. Peluso et al. (2019) study suggests that improved overall quality delivered provides increased reimbursements to the providers when specific quality benchmarks are met. Quality healthcare is composed of various dimensions such as efficiency, appropriateness and customer satisfaction, evaluation of standard and effectiveness, and is evaluated at my employer by conducting surveys by a staff nurse during the patient’s hospital stay and one week post discharge through either telephone, email, or text message (Peluso et al., 2019). The conducted study results in Peluso et al. (2019) displayed that the implementation of the pay-for-performance arrangement positively impacted the healthcare system, with evidence of detrimental health outcomes curtailed and healthcare services provided were enhanced.  

 

 

Peluso, A., Berta, P., & Vinciotti. (2019). Do pay-for-performance incentives lead to a better health

outcome? Empirical Economics, 56(6), 2167-2184. https://doi.org/10.1007/s00181-018-1425-8

 

Toseef, M. U., Jensen, G. A., & Tarraf, W. (2020). Medicaid managed care and preventable emergency

department visits in the United States. PLoS One, 15(10), 1-15. https://doi.org/10.1371/journal.pone.0240603