Question

For Hospital-Based Care

Describe the types of care provided.

Identify the national organization(s) and the healthcare standards for the setting.

Identify your home state for state specific information

Summarize the state specific health record (i.e., medical record) documentation guidelines for the healthcare setting, including the statute, regulation and administrative code reference number.

Summarize the state specific health record (i.e., medical record) retention guidelines for the health care setting, including the statute, regulation and administrative code reference number.

Summarize the documentation requirements from The Joint Commission, including the standard and section (only for hospital-based care).

Describe the reimbursement method for the healthcare setting.

Describe a minimum of two coding or classifications systems utilized.

Summarize at least one commonly reported database associated with the health care setting.

Answer 1

Every individual has required different care depending upon their health problem like some require normal care and some require extra special care. So on the basis of patient condition healthcare divides into various types. Following types of healthcare are explained below:

(i) Primary Healthcare:
Primary health care mainly focuses on health equity producing social policy beyond the traditional healthcare system. Its main aim is to provide local care to a patient because professionals related to primary care are normal generalists, deals with a broad range of psychological, physical and social problems etc rather than specialists in any particular disease area. Primary care services rapidly increasing in both the developed and developing countries depending upon the increasing number of adults at greater risk of chronic noncommunicable disease like diabetes, asthma, back pain, hypertension, anxiety, depression etc.

To achieve the ultimate goals of primary health care., WHO has described five elements to achieve this goal. Following are:

• Stakeholder participation increased.
• Integrate health into all sectors.
• According to people need & expectation organizing healthy services.
• Pursuing collaborative models of policy dialogue.

(ii) Secondary Healthcare:
This healthcare is provided by the medical specialists and other health problems who do not have direct contact with a patient like urologists, dermatologists, cardiologists etc. According to National health system policy, the patient required primary care professionals referral to proceed further for secondary care. Depends on countries to countries, the patient cannot directly take secondary care because sometimes health system imposed a restriction of referral on a patient in terms of payment.

The systems come under this category is known as District Health system and County Health system.

(a) District Health system : This system mainly focus on child health and maternity care. People population of this system is about 25000 to 50000 and includes various healthcare centres and district hospitals. Healthcare centres receive referrals from various primary health care and is remain open for 24 hours every day. District hospitals include emergency services, neonatal care, comprehensive emergency obstetric etc and is remain open for 24 hours every day.

(b) County Health system: Into this system, hospitals receive referrals from the District & community health systems. County hospital provides gynecologic services, general medicine, obstetrics, general surgery etc and is remain open for 24 hours every day.

(iii) Tertiary Healthcare:
This type of healthcare is known as specialized consultative healthcare usually for inpatients and on referral from primary and secondary healthcare for advanced medical investigation and treatment. following examples of tertiary care services are plastic surgery, burn treatment, cardiac surgery, cancer management, neurosurgery, complex medical and surgical interventions etc.

The main provider of tertiary care is national Health system consist of Regional hospitals and National Hospital. Regional hospitals receive a reference from various county hospitals and serves as training sites complementary to the National referral hospital. It also provides additional care services and remains open for 24 hours every day.

Types of Care

In-Home Care
As the name suggests, in-home care takes place at home. It may be care provided by loved ones, family, friends, neighbors or professional caregivers. In-home care typically includes assistance with day-to-day tasks such as bathing, walking or cooking. If care needs are more extensive or medically intensive, in-home care may not be able to meet them. Area hospitals, care agencies or therapists may offer training sessions to help caregivers learn how to provide quality care and avoid caregiver stress.

Respite Care
Respite care is a short term relief program that gives caregivers a break. In respite care, a skilled care professional assumes caregiver responsibilities for a predetermined amount of time. Respite care may range from a few hours to a few weeks. It helps caregivers reenergize, reduce stress and address personal needs that may have become neglected because of care responsibilities. Respite care can take place at home or at a center, such as an adult day care center or Skilled Nursing Care center.

Adult Day Care
Adult day care or “adult day service” offers part- or full-time care in a group setting. Adult day care is an appropriate choice for those who are unable to stay at home alone, even for short periods. Adult day care offers supervised care within a safe and secure environment. It may be community- or facility-based. Services typically include meals, social or recreational activities, and health-related assistance.

Assisted Living
Assisted living care facilities, sometimes called “residential care centers,” offer a home-like setting, plus varying levels of supervision and personal or medical care. Assisted living is appropriate for individuals who are no longer able to live alone, but who do not require extensive care.

Skilled Nursing Care
Nursing homes, professionally called Skilled Nursing Care centers, offer 24-hour staffing to provide comprehensive services to those requiring a greater level of care than that offered by assisted living facilities. All Skilled Nursing Care centers require the professional skills of a registered nurse (RN) or licensed practical nurse (LPN). With 24-hour nursing care and many of the comforts of home, Skilled Nursing Care centers balance quality care and quality of life. These centers promote autonomy and choice, and offer a variety of services, social activities, and recreational opportunities. Residents are encouraged to continue social activities and personal interests. Today's Skilled Nursing Care centers offer services ranging from short-term rehabilitative care to long term extended care. Services can be grouped into three general care categories: medical, nursing and rehabilitative, and personal.

Assisted living facilities vary greatly in how many residents can live there and can range from a private room or an apartment to a multi-unit facility. In general, they promote self-sufficiency and are designed to offer residents a high level of independence. Service options, like accommodations, vary widely, especially from state to state. Care can include assistance with daily tasks, such as bathing, dressing or help with medications. Facilities might offer social activities or meal, laundry or housekeeping services.

Medical Care
Medical care in a Skilled Nursing Care center may be one-to-one (attending physician) or one-to-many (medical director). These physicians oversee medications, examinations and treatments. They work with staff, residents and families to develop care plans.

Nursing and Rehabilitative Care
Nursing services include assessment, treatments, injections, and administration of medications. Rehabilitative care services might include post-hospital stroke, heart or orthopedic care, or various types of therapy, e.g. respiratory, physical, occupational or speech therapy.

Certified nursing assistants (CNAs) provide much of this care.

Rehabilitative Care
Rehabilitative services assist patients recovering from illness, injury or disease. Rehabilitative treatments help patients regain abilities recently lost. Services might include post-hospital stroke, heart or orthopedic care, or various types of therapy (e.g., physical, occupational or speech therapy). Dietary consultation, laboratory, x-ray and pharmaceutical services may also be included in rehabilitative settings.

Personal Care
Personal care offers assistance with “activities of daily living.” These daily tasks can include help getting out of bed, bathing, using the toilet, dressing, walking or eating.

Dementia Care
Dementia is the general term used to describe a set of symptoms that affect intellectual and social abilities, such as memory, problem solving and communication. Alzheimer’s is the most common form of dementia. Each person’s symptoms and progression differ. Consequently, there are many treatments and care options available for people diagnosed with dementia.

Hospice Care
Hospice care offers comfort and support to those nearing the end of life. Hospice is a care philosophy focused on reducing suffering rather than curing a condition. Hospice addresses physical, spiritual, social and emotional needs of dying individuals and loved ones. Hospice care can include pain medication, therapy or counseling.

Veterans Care
The U.S. Department of Veterans Affairs (VA) offers support programs for veterans and their caregivers. The VA provides support and services for those who care for veterans, as well as short-stay and long-stay nursing home care. Learn more about Health Programs for Veterans.

National Standards and Accreditation
Accreditation and the National Safety and Quality Health Service (NSQHS) Standards. The Commission developed the National Safety and Quality Health Service (NSQHS) Standards to drive the implementation of safety and quality systems and improve the quality of health care.

Clinical Care Standards
The Commission is working to formulate and monitor safety and quality standards and work with clinicians to identify best practice clinical care, to ensure the appropriateness of services being delivered in a particular health care setting.

National Standards in Mental Health Services
The Commission has a strong commitment to promote, support and encourage safety and quality in the provision of mental health services. In 2011, the Mental Health Team was established to ensure a greater integrated focus across existing ACSQHC programs.The mental health team works with colleagues across the range of ACSQHC programs including, Health Service Standards and Accreditation, Information Strategy, Medication Safety and Recognition and Response to Clinical Deterioration.

A standards organization, standards body, standards developing organization (SDO), or standards setting organization (SSO) is an organization whose primary activities are developing, coordinating, promulgating, revising, amending, reissuing, interpreting, or otherwise producing technical standards that are intended to address the needs of a group of affected adopters.

Most standards are voluntary in the sense that they are offered for adoption by people or industry without being mandated in law. Some standards become mandatory when they are adopted by regulators as legal requirements in particular domains.

Joint Commission state-of-the-art standards are the basis of an objective evaluation process and can help organizations measure, assess and improve performance. The standards focus on important patient, individual, or resident care and organization functions that are essential to providing safe, high-quality care. Joint Commission standards are developed with input from health care professionals, providers, subject matter experts, consumers, and government agencies (including the Centers for Medicare & Medicaid Services). They are informed by scientific literature and expert consensus. New standards are added only if they relate to patient safety or quality of care, have a positive impact on health outcomes, meet or surpass law and regulation, and can be accurately and readily measured.

The standards development process includes the following steps:

• Emerging quality and safety issues suggesting the need for additional or modified requirements are identified through the scientific literature or discussions with The Joint Commission’s standing committees and advisory groups, accredited organizations, professional associations, consumer groups or others.
• The Joint Commission prepares draft standards using input from technical advisory panels, focus groups, experts and other stakeholders.
• The draft standards are distributed nationally for review and made available for comment on the Standards Field Review page of The Joint Commission website.
• After any necessary revisions, standards are reviewed and approved by executive leadership.
• The survey process is enhanced, as needed, to address the new standards requirements, and pilot testing of the survey process is conducted.
• Surveyors are educated about how to assess compliance with the new standards.
• The approved standards are published for use by the field.
• Once a standard is in effect, ongoing feedback is sought for the purpose of continuous improvement.

Regardless of the payer for a particular healthcare service, only a limited number of payment methodologies are used to reimburse providers. Payment methodologies fall into two broad classifications: fee-for-service and capitation.

In fee-for-service payment, of which many variations exist, the greater the amount of services provided, the higher the amount of reimbursement. Under capitation, a fixed payment is made to providers for each covered life, or enrollee, that is independent of the amount of services provided.

Fee-for-Service Methods
The three primary fee-for-service methods of reimbursement are cost based, charge based, and prospective payment.

Cost-Based Reimbursement
Under cost-based reimbursement, the payer agrees to reimburse the provider for the costs incurred in providing services to the insured population. Reimbursement is limited to allowable costs, usually defined as those costs directly related to the provision of healthcare services. Nevertheless, for all practical purposes, cost-based reimbursement guarantees that a provider’s costs will be covered by payments from the payer. Typically, the payer makes periodic interim payments (PIPs) to the provider, and a final reconciliation is made after the contract period expires and all costs have been processed through the provider’s managerial (cost) accounting system.

Charge-Based Reimbursement
When payers pay billed charges, or simply charges, they pay according to a rate schedule established by the provider, called a chargemaster. To a certain extent, this reimbursement system places payers at the mercy of providers in regards to the cost of healthcare services, especially in markets where competition is limited. In the early days of health insurance, all payers reimbursed providers on the basis of billed charges. Some insurers still reimburse providers according to billed charges, but the trend for payers is toward other, less generous reimbursement methods. If this trend continues, the only payers that will be expected to pay billed charges are self-pay, or private-pay, patients. Even then,
low-income patients often are billed at rates less than charges. Some payers that historically have reimbursed providers on the basis of billed charges now pay by negotiated, or discounted, charges. This is especially true for insurers that have established managed care plans. Additionally, many conventional insurers have bargaining power because of the large number of patients that they bring to a provider, so they can negotiate discounts from billed charges. Such discounts generally range from 20 to 50 percent, or even more, of billed charges. The effect of these discounts is to create a system similar to hotel or airline pricing, where there are listed rates (chargemaster prices for providers, and rack rates or full fares for hotels and airlines) that few people pay.

Prospective payment
In a prospective payment system, the rates paid by payers are established by the payer before the services are provided. Furthermore, payments are not directly related to either costs or chargemaster rates. Here are some common units of payment used in prospective payment systems:

• Per procedure. Under per procedure reimbursement, a separate payment is made for each procedure performed on a patient. Because of the high administrative costs associated with this method when applied to complex diagnoses, per procedure reimbursement is more commonly used in outpatient than in inpatient settings.
• Per diagnosis. In the per diagnosis reimbursement method, the provider is paid a rate that depends on the patient’s diagnosis. Diagnoses that require higher resource utilization, and hence are more costly to treat, have higher reimbursement rates. Medicare pioneered this basis of payment in its diagnosis-related group (DRG) system, which it first used for hospital inpatient reimbursement in 1983.
• Per day (per diem). If reimbursement is based on a per diem payment, the provider is paid a fixed amount for each day that service is provided, regardless of the nature of the service. Note that per diem rates, which are applicable only to inpatient settings, can be stratified. For example, a hospital may be paid one rate for a medical/surgical day, a higher rate for a critical care unit day, and yet a different rate for an obstetrics day. Stratified per diems recognize that providers incur widely different daily costs for providing different types of care.
• Bundled. Under bundled payment, payers make a single prospective payment that covers all services delivered in a single episode, whether the services are rendered by a single provider or by multiple providers. For example, a bundled payment may be made for all obstetric services associated with a pregnancy provided by a single physician, including all prenatal and postnatal visits as well as the delivery. For another example, a bundled payment may be made for all physician and hospital services associated with a cardiac bypass operation. Finally, note that, at the extreme, a bundled payment may cover an entire population.

Medical Coding: The Foundation of Fee-for-Service Reimbursement
Medical coding, or medical classification, is the process of transforming descriptions of medical diagnoses and procedures into code numbers that can be universally recognized and interpreted. The diagnoses and procedures are usually taken from a variety of sources within the medical record, such
as doctor’s notes, laboratory results, and radiological tests. In practice, the basis for most fee-for-service reimbursement is the patient’s diagnosis (in the case of inpatient settings) or the procedures performed on the patient (in the case of outpatient settings). Thus, a brief background on clinical coding will enhance your understanding of the reimbursement process.

Diagnosis Codes
The International Classification of Diseases (most commonly known by the abbreviation ICD) is the standard for designating diseases plus a wide variety of signs, symptoms, and external causes of injury. Published by the World Health Organization, ICD codes are used internationally to record many types of health events, including hospital inpatient stays and death certificates. (ICD codes were first used in 1893 to report death statistics.) The codes are periodically revised; the most recent version is ICD-10. However, US hospitals are still using a modified version of the ninth revision, called ICD-9-CM, where CM stands for Clinical Modification. The ICD-9 codes consist of three, four, or five digits. The first three digits denote the disease category, and the fourth and fifth digits provide additional information. For example, code 410 describes an acute myocardial infarction (heart attack), while code 410.1 is an attack involving the anterior wall of the heart. (However, it is expected that conversion to ICD-10 codes will occur October 1, 2015. The conversion process is consuming and costly because there are more than five times as many individual codes in ICD-10 as in ICD-9. Of course, the information provided by the new code set will be more detailed and complete.) In practice, the application of ICD codes to diagnoses is complicated and technical. Hospital coders have to understand the coding system and the medical terminology and abbreviations used by clinicians. Because of this complexity, and because proper coding can mean higher reimbursement from third-party payers, ICD coders require a great deal of training and experience to be most effective.

Procedure Codes
While ICD codes are used to specify diseases, Current Procedural Terminology (CPT) codes are used to specify medical procedures (treatments). CPT codes were developed and are copyrighted by the American Medical Association. The purpose of CPT is to create a uniform language (set of descriptive
terms and codes) that accurately describes medical, surgical, and diagnostic procedures. CPT and its corresponding codes are revised periodically to reflect current trends in clinical treatments. To increase standardization and the use of electronic health records, federal law requires that physicians and other
clinical providers, including laboratory and diagnostic services, use CPT for the coding and transfer of healthcare information. (The same law also requires that ICD codes be used for hospital inpatient services.)