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Chapter 7 Outpatient and Primary Care Services Learning Objectives • To know the difference between outpatient, ambulatory, and primary care • To identify why there is growth in outpatient care • To identify various outpatient settings and services • To appreciate complementary and alternative medicine in health care • To understand the various provisions in the Affordable Care Act that apply to outpatient services Outpatient and Primary Care Services • Outpatient existed before hospitals and nursing homes • Hospitals major player in outpatient services • Hospitals capitalized on technology to compete on an outpatient basis • Hospital labs and diagnostic better equipped • Solo practices consolidated to cope • Outpatient helps serve underserved population Outpatient and Primary Care Services • Community health centers receive federal and state money to serve rural and inner cities • “Outpatient” is more comprehensive • Ambulatory care more diagnostic and therapeutic to the “walking” (ambulatory) • Outpatient and Ambulatory care used interchangeably Primary Care • Basic, routine, continuous, coordinated, and comprehensive care • An approach to delivering health care rather than a set of services • Includes primary and secondary prevention and sometimes tertiary Outpatient Primary Care Services • Primary care is: – Integrated health care services – By clinicians who are accountable for: • Addressing personal health care needs • Developing a partnership with patients • Practicing in the context of family and community Outpatient Care • Ambulatory Care – Care rendered to patients who come to the physician office, clinics, or outpatient surgery • Mobile diagnostic units and home health – Take services to patients Outpatient Care • Does not require overnight stay incurring room and board costs • Ambulatory care similar to “community medicine” because it serves: – Surrounding community – Convenience – Accessibility • The most basic outpatient services: – Physicals and minor treatment in physician office Scope of Outpatient Services • Great growth in outpatient: – Services – New settings – Types – Ownership – See Table 7 − 1 • Basic services in group practices: – Physical exams – Minor treatment • Advanced outpatient in a hospital-base Scope of Outpatient Services • Hospital inpatient services continues decline • Executives see Ambulatory Care as an essential, no longer a supplemental service line • Hospital survival can depend heavily on Ambulatory Care • Competition from home health agencies, Ambulatory Care, urgent care, outpatient surgery Scope of Outpatient Services • Primary care – The foundation for Ambulatory Care • All primary care is outpatient, but not all outpatient care is primary care (i.e., emergency room, urgent care treatment, outpatient surgery, rehabilitation, renal dialysis, chemotherapy) Outpatient Primary Care Service Sites • Physician Offices • Hospital Emergency Services • Primary Care Center • Emergent/Urgent Care Centers • Ambulatory Care Surgery Centers • Community Health Centers Primary Care • Plays a central role in a health care delivery system • Focus on the type or level of services – Prevention – Diagnostic – Therapeutic services – Health education – Counseling – Minor surgery Primary Care Services • Coordination of care – Delivery of health services between the patient and the different components of the delivery system – Refer patients to sources of specialized care – Give advice regarding various diagnosis and therapies – Discuss treatment options – Provide continuing care of chronic conditions Secondary Care • Usually short term • Sporadic consultation from a specialist • Includes hospitalization • Routine surgery • Specialty consultation • Rehabilitation Tertiary Care • Most complex level of care • For conditions that are uncommon • Usually institution based • Highly specialized • Technology-driven • Rendered in large teaching hospitals • May be long-term care • E.g., trauma, burn treatment, NICU, transplants, open heart surgery Health Care Service Frequency • Primary Care – 75 − 85% of population requires only primary • Secondary Care – 10 − 12% requires referral to short-term secondary care • Tertiary care – 5 − 10% require tertiary World Health Organization Definition of Primary Health Care • Essential health care based on scientific acceptable methods • Universally accessible and acceptable • At an affordable cost • To maintain at every developmental stage • The first level of contact • Bringing health care as close as possible to where people live and work • As part of a continuing health care process World Health Organization Definition of Primary Health Care • Three key elements – Point of Entry – Coordination of Care – Essential Care World Health Organization Definition of Primary Health Care • Point of Entry – Into the health care system where health care is organized around primary care – The first contact a patient makes with the delivery system – Role of a gatekeeper: patients cannot see a specialist or be admitted without a physician referral – Goal: bring it as close to the population as possible World Health Organization Definition of Primary Health Care • Coordination of Care – To coordinate health care between patient and the many delivery components of the system – Primary care professional serve as advisors, advocates, gatekeepers – Meant to ensure continuity and comprehensiveness – Countries geared to primary care have better health levels, satisfaction and lower expenses – Primary care helps mitigate the adverse health effects of income inequality World Health Organization Definition of Primary Health Care • Essential Care – Primary health care is regarded as essential health care • Goal – To optimize population health – Disparities must be minimized to ensure equal access Institute of Medicine Definition • Integrated – Comprehensiveness, coordinated, continuous, seamless • Comprehensive – Addresses any health problem at any stage of a person’s life cycle • Coordinating – Combining health services to best meet the patient’s needs • Continuity – Care over time Institute of Medicine Definition • Accessibility – Ease that a patient can interact with a clinician for any health problem • Accountability – Clinical system • To provide quality care, patient satisfaction, use of resources efficiently, behaving ethically – Patient • Responsible for own health that they can influence • Judicious use of resources Outpatient Primary Service: Reasons for Growth • Changes in reimbursement – Constraining inpatient services – Favoring outpatient services • Fewer payment restrictions – Surgery, dialysis, chemotherapy – Paid as fee-for-service Outpatient Service: Reasons for Growth • Development of New Technology – Less invasive procedure – Quicker recuperation from surgery • Utilization Controls – Managed care restriction on utilization, quicker discharge • Prior authorization (precertification) • Utilization review • Social Factors – Preference for obtaining services at home or in community based settings, especially long-term care Outpatient Service • Services provided – Diagnosis of illness or disease and initial treatment given – Episodic care for common, nonchronic illnesses and injuries – Prescription drugs to treat common illnesses or injuries – Routine dental care – Physical and mental health condition require referral Outpatient Care Settings: Private Practice • Shift from independent solo practice to group practice and institutional employment • Group practice advantages – Lower operating cost (start up, sharing of overhead, equipment and diagnostics) – Greater opportunities to contract with managed care • Group practice advantages for patients – Routine services available at one place – Cross referrals Hospital-Based Outpatient Care Services: Five Main Types 1. Clinical Services: Special consultation 2. Surgical Services 3. Emergency Services for Acute Services – Emergent require immediate attention – Urgent require attention within a few hours – Nonurgent, nonemergency (used by mostly uninsured as a substitute for primary care) Hospital-Based Outpatient Care Services: Five Main Types 4. Home Health Care 5. Women’s Health Center – Women are major users of health care due to a female majority – Change in culture towards women’s equality – A national priority Outpatient Care Services: Free Standing Facilities • Walk-in Clinics – Ambulatory care from basic primary to urgent care – Nonroutine, episodic basis – Convenient • Urgicenters – Usually open 24/7 – Wide range of routine services – First come first serve basis – Not comparable to Emergency Department Outpatient Care Services: Free Standing Facilities • Surgicenters – Freestanding, independent of hospitals – Full range of services for surgeries – Outpatient, no overnight Outpatient Care Services: Other Types • Mobile Medical, Diagnosis and Screening Service – Mobile Health Units • Transported to patients (i.e., ambulances with Emergency Medical Technicians) • Mobile eye, dental, immunizations – Mobile Diagnostic Care Unit • Mammography • MRI Outpatient Care Services: Home Health • Services brought into the home – Nursing care – Medication monitoring – Bathing – Short-term rehabilitation (PT, OT, ST) – Homemaker service (meal prep, shopping, transportation, medical equip, chores) • DME–durable medical equipment – Wheelchairs, oxygen, beds, walkers, commodes • Alternative would be institutionalization – See Figure 7 − 7 – See Figure 7 − 8 Outpatient Care Services: Hospice • Comprehensive services for the terminally ill with life expectance of 6 months or less – Staffing on 24 hours basis – Medical and nursing care – Access to inpatient care – Social services and support – Therapy and access to supplies (See Table 7 − 4 and Figure 7 − 9) • Two Areas of Emphasis – Palliation − Pain management – Psychosocial and spiritual support Outpatient Care Services • Ambulatory Long-Term Care Services – Nursing homes – Case Management • Coordination and referral • Finding the most appropriate care – Adult Day Health Care Outpatient Care Services • Public Health Service – Immunizations to a full range of inpatient and outpatient services – From preventive service to treatment • Public and Voluntary Clinics – Community Health Centers – Free Clinics – Other Clinics Outpatient Care Services • Complementary and Alternative Medicine (CAM) • Telephone Access – Telephone triage: Giving expert opinion and advice to the patient, especially during hours when a physician’s office is usually closed • Utilization of Outpatient Care Services – See Table 7 − 5 ACA Takeaway • Primary care, specialty care, and hospital emergency departments are expected to be overburdened with an influx of newly insured patients. • The need for providing uncompensated care by hospitals is expected to decrease. • Components of the ACA that affect community health centers involve maintaining adequate funding and developing teaching health centers. Health centers located in states that do not expand Medicaid could face fiscal shortfalls.