Health Care : A Model Continuum Of Care

The program should be able to instruct patients and their caregivers how to self manage their diseases. The goal of the Continuum of care is to avoid unnecessary hospitalization. Most agencies are focused on Heart Failure, Diabetes, Incontinence, COPD, rehabilitation, psychiatric nursing, wound care and after surgery care. Continuum of care therapy program is designed to improve self care, problems with mobility, communication, pain and even swallowing management.

Roemer’s model of a health care delivery system shows the different necessary elements for a system to be successful. As health needs are the input; the system needs resources, organization of programs, economic support mechanisms, and delivery of services to provide the health needs output (Roemer, p 33). Able 2 is an organization that provides services to people with disabilities. They have many resources, but perhaps not enough to meet the health needs of every consumer. They have well organized programs, have economic support, and can deliver services completely and holistically to produce health as the output of the client. The most important implication that was found in analyzing Able 2 was the need for increased resources as they are not able to meet the needs for every client in need of its services. Ultimately though, Able 2 is an excellent organization that provides an array of services for those people with disabilities.

Patient-Centered Medical Homes (PCMH) are growing in popularity as the right thing to do improve patient care. PCMH are growing in popularity, as there is early evidence of their effectiveness (Egge, M. 2012). The PCMH concept has been widely promoted as a way to enhance primary care and deliver better care to patients with chronic conditions. This model of care has stimulated the attention of payers, Medicaid policy makers, physicians, and patient advocates, as it has the potential to address several of the limitations of the current healthcare system (Wang, J. et al 2014). Currently, primary care in the United States is focused on acute and episodic illness, it inadvertently limits comprehensive, coordinated, preventive and chronic care (Bleser, W. et al 2014). The PCMH address these limitations through organizing patient care, emphasizing team work, and coordinating data tracking (Bleser, W. et al 2014). A PCMH and HMO have some similarities but are markedly different.

The primary care practice is essential to improve the care of our population, our current system is fragmented, but it does show potential for improvement. The Agency for Healthcare Research and Quality has listed some areas that will help improve our system. One is “the need for external infrastructure to help primary care practices develop quality improvement” this is done with support to the quality capacity (Agency For Healthcare Research and Quality, 2015). Quality care will include the coordination of care within the system, as well as understanding what needs the patient will have

Healthcare is often driven by consumers and insurance companies; there is strong pushes for insurance companies to start paying better through Patient Care Medical Homes (PCMH) or Accountable Care Organizations (ACO) rather than paying at a per-visit basis (Hamlin, 2015). With PCMH or ACOs payment is made on a continuum of care, encouraging the provider to be involved in all aspects affecting health of the patient (Derksen, & Whelan,

Long-term care is a variety of services that includes medical and non-medical care to people who have a chronic illness or disability. Long-term care helps meet health or personal needs. Most long-term care is to assist people with support services such as activities of daily living like dressing, bathing, eating, and using the bathroom. Long-term care can be provided at home, in the community, in assisted living or in nursing homes. Long-term care can be given at any age depending on

The underserved populations have increased exponentially. The Rural Policy Research Institute (2009) defines the medically underserved as, “the ratio of primary care physicians per 1,000 population, the infant mortality rate, the percent of the population with incomes below the poverty level, and the percent of the population age 65 and over.” By that definition, over half the state is considered to be an underserved population. With the demand and needs of the state, it is no surprise that the FNP has become a more utilized provider of healthcare is many settings. There has also been a recent emergence of nurse-managed health centers or (NMHCs), as a form of primary care delivery. According to Espirat and Debisette (2012), NMHCs reduce Medicaid costs, are a great Segway to community outreach and provide quality primary prevention.

Accountable care organizations (ACOs) try to find to ways to redesign the method of care is

Throughout Unit 6 we reviewed the continuum of care in long-term care facilities and its many aspects. The continuum of care, also referred to as the delivery system of health care, is best defined as a full range of long-term care services increasing in level of acuity and complexity from one end to the other (PowerPoint). This delivery system is comprised of three substantial components. These components are the informal system, community based care, and the institutional system.

One of the aims of the Patient Protection and Affordable Care Act (ACA) of 2010 is improved integration and coordination of services for primary patient care. The patient-centered medical home (PCMH) is one of the approaches by which improvements can be established. The patient-centered medical home model is particularly well-suited for people who have chronic illness. The design of the patient-centered medical home model departs substantively from traditional reimbursement policies, in that, the ACA provides for incentives and resources to enable care coordinators to be directly recognized and compensated for their care coordination work. Care coordinators are most often registered nurses who through their work that aligns with ACA engage in quality improvement work, cost-effectiveness measures, and patient advocacy. To bring the ACA model to a human scale, the authors present a case study of a care coordinator at a patient-centered medical home in rural Maine. The table provided below provides a basic textual analysis of the study as it is published in the professional nursing journal.

With the implementation of two milestone in the healthcare system, the Affordable Care Act (ACA) and Health care education and reconciliation act of 2010. The ACA assist in easy access to high-quality and cost-effective and also assist in the shift of the nation’s health care system in the direction of primary and preventive care. Also the health care education and reconciliation act is an initiative to motivate nurses and provide grants and scholarships to acquire higher education and take active part in the reformed health care system. In order to create the health care system which focus on primary and preventive care, the role of nurses is very vital and important especially the advanced practice registered nurses (APRN) (Implementing Health Care Reform: Issues for Nursing, 2010). American Nurses Association always advocate and nurture nurses including APRNs and Patient Protection and Affordable Care Act (PPACA) also acknowledged and recognized the role of APRNs in the provision of primary and preventive care. This acknowledgement of PPACA open the new horizon for the APRNs in the transformed patient-centered care system (Haney, 2010). In this presentation, the writer will discuss new emerging care delivery model which are mentioned in the PPACA. These delivery model involve interdisciplinary and care management services of RNs (The National Academies Press, 2011).

Health care systems are made to improve and provide quality, efficient care, work in a more collective fashion to improve patient care and reduce overall healthcare cost. They must be mindful of wasteful spending and become more accountable to a diverse patient population.

As the continued support grows the PCPCC, the health care sector is recognizing the role of the medical home model, Accountable Care Organizations(ACO), many entities are embracing the model and performing better. According to Center of Medicare and Medicaid, the medical home model shows that there is an improvement cost effectiveness, which helps practitioners deliver quality care and advanced approaches to care coordination, care teams, and chronic disease management. As evaluations of ACOs, integrated health systems, and the medical neighborhood continue, the Patient Center Medical Home will be essential to driving improvements in cost, quality, and outcomes. [3]

The first ACO model started January 1, 2012 and consisted of 32 ACOs with 860,000 beneficiaries (CMS, 2016). ACOs are made up of groups of hospital, doctors, and other health care providers who provide coordinated high quality care to their patients. The goal of this coordinated care is to ensure patients receive the appropriate care in a timely manner while avoiding unnecessary services and duplication of services. The expected end result is the delivery of high quality care and reduction of health care cost and the incentive for the health care provider to meet the goal is the share of the savings they will receive. As stated by Dr. Berwick, (Its (ACOs) purpose is to foster change in patient care so as to accelerate progress toward a three-part aim: better care for individuals, better health for populations, and slower growth in costs through improvements in care” (Berwick, 2011). The ACO providers are held responsible for meeting quality improvement measures while reducing their rate of spending.

You mentioned that your community lacks support or services for the homeless. The federal government created two programs in 2004 on order to reduce the homeless population. They are the Continuum of Care concept and the Homeless Information Management System. The Continuum of Care Concept provides housing for the homeless (Nies & McEwen, 2015). These programs are not able to provide housing for all the homeless, but it helps decrease the amount of homelessness. Do you know if your community uses these federal programs?