Examl 1:l NSGl 444/l NSG444l (NEWl 2025/l
2026l Update)l Transitionl tol Practicel Guide|l Questionsl &l Answers|l Gradel A|l 100%l Correctl (Verifiedl Solutions)-l GCU
Q:l ACA
Answer:
passedl inl 2010 -madel insurancel morel affordablel tol thosel bwl 100-400%l ofl thel federall povertyl line -expandl medicaidl tol thosel belowl thel 138%l FDLl -setl servicesl thatl insurancel mustl pay -insurersl cannotl denyl someonel duel tol preexistingl healthl conditions,l cantl chargel higherl basedl onl healthl history,l andl cannotl dropl someonel ifl theyl becomel ill -everyonel mustl havel insurancel orl payl al tax -reducel healthcarel costsl asl thel resultl ofl poorl care -kidsl canl stayl onl parentsl insurancel untill 26 -fundingl forl research -widerl usel ofl technology -increasedl incentivesl forl coordinationl ofl carel -increasingl consumerl outl ofl pocketl costs
Q:l managedl care
Answer:
inl 1980,l proposedl byl medicarel tol changel froml al feel forl servicel approachl tol al fixedl ratel (prospectivel paymentl system) >feel forl servicel wasl causingl spiralingl healthcarel costsl inl thel 1960's >downsidesl tol feel forl service:l placesl emphasisl onl illnessl notl prevention,l copaysl deterl patientsl froml reportingl illnessl inl earlyl stages -patientl willl payl al setl amountl basedl onl theirl diagnosisl onl admission,l thisl givesl hospitalsl incentivel tol providel efficientl carel -capitationl isl al forml ofl managedl care:l employersl whol providel insurancel tol theirl employeesl payl al monthlyl feel forl eachl employeel andl theirl dependents.l thisl costl doesl notl changel whetherl peoplel needl thel medicall carel orl notl ***Clientl carel isl outcomel drivenl andl isl managedl byl al casel managementl process.
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HEALTHl MAINTENANCEl ORGANIZATIONl (HMO) -typel ofl insurancel planl wherel membersl payl al setl annuall feel tol multiplel providersl sol theyl arel coveredl forl al widel rangel ofl services -thisl madel thel hospitalsl focusl onl preventativel servicesl tol reducel patientl stays
PREFERREDl PROVIDERl ORGANIZATION -patientl paysl al groupl ofl providersl inl networkl whol havel agreedl tol chargel lessl tol reducel outl ofl pocketl costsl -ifl theyl gol withoutl referrall tol anl outl ofl networkl personl itl willl costl more -thisl wasl createdl sol patientsl havel freedoml overl whichl providersl theyl seel *openl accessl plansl arel similarl tol thisl
MANAGEDl CAREl AFFECTSl ONl HOSPITALS -individuall hospitalsl tol mergel intol largel organizations -hospitalsl wentl froml nonl profitl tol forl profit -workl environmentl nowl involvesl corporatel culturel
*pointl ofl servicel plansl arel al combol bwl PPOl andl HMO
Q:l accountablel carel organization
Answer:
al groupl ofl hospitalsl andl HCPl thatl comel togetherl voluntarilyl tol servel thel medicarel patients -thisl isl especiallyl importantl forl thosel wl chronicl illnessl bcl itl ensuresl theyl arel gettingl thel rightl carel atl thel rightl time
Q:l payl forl performance
Answer:
VALUEl BASED -l Itl isl seenl asl thel bestl methodl forl loweringl healthl carel costsl whilel alsol increasingl quality.
thisl isl al valuel basedl carel approach -makel feel forl servicel cheaperl andl thenl usel thosel fundsl tol rewardl hospitalsl forl goodl care -orl theyl financiallyl penalizel hospitalsl forl providingl poorl care
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Q:l integratedl healthcarel deliveryl system
Answer:
-offersl preventative,l acute,l longl term,l homel health,l andl hospicel care -greaterl degreel ofl continuityl ofl care
Q:l casel management
Answer:
-coordinationl ofl carel whilel reducingl costs -assess,l plan,l evaluatel thel carel andl servicesl al patientl willl needl -diseasel managementl forl betterl outcomes -deall wl chronicl diseasel andl whenl patientsl needl carel afterl thel hospitall (dontl deall wl acute) -strivesl tol achievel predeterminedl ptl outcomes
PTl WHOl NEEDl Al CASEl MANAGER -complicatedl andl expensivel care/illness -dischargel planningl issues -ppll receivingl carel froml multiplel providers -ppll likelyl tol havel significantl physicall orl psychologicall issuesl
TYPESl OFl CASEl MANAGEMENT 1.l traditionall role:l focusl onl dischargel planningl andl determiningl ifl carel wasl necessaryl sol thel insurerl willl payl it -havel morel patients,l reviewl thel chartl 1-2xl week 2.l Fulll immersionl role:l reviewl thel chartsl dailyl andl communicatel withl thel nursel andl physician -hadl fewerl patients 3.l Nursel navigatorl role:l reducel barriersl forl vulnerablel patientsl whol mayl bel facingl fragmentedl carel orl delaysl inl carel -hasl ledl tol improvedl patientl satisfaction -alsol teachl ptl abtl theirl diseasel andl offerl resources -takesl ptl froml onel placel inl thel hospitall tol thel nextl (throughl healthl problemsl inl al system)
TOOLSl FORl CASEl MANAGEMENT
1.l clinicall pathways:l "carel plans"
-timeline,l interventions,l short-l andl long-terml outcomes,l andl al variancel recordl (documentl whenl andl whyl thel clientsl progressl deviatedl froml thel plan/timeline) 2.l diseasel managementl protocol:l focusl onl prevention,l improvel patient-HCPl relationship
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