Introduction to Healthcare and Public Health in the US

1. Introduction to Healthcareand Public Health in the US Delivering Healthcare (Part 1) Lecture d This material (Comp1_Unit2d) was developed by Oregon Health and Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015.

2. Delivering Healthcare (Part 1)Learning Objectives • Describe the organization of healthcare at the federal, state and local levels (Lecture a) • Describe the organization of the VA system and Military Health System (Lecture b) • Describe the structure and function of hospital clinical and administrative units (Lecture c) • Describe different types of long term care facilities, with an emphasis on their function (Lecture d) Introduction to Healthcare and Public Health in the US Delivering Healthcare (part 1) Lecture d

3. Delivering Healthcare (part 1) Learning Objectives • Describe a variety of healthcare settings, with emphasis on their function, including: • School-based health centers • Home healthcare • Group living • Assisted living, retirement communities, nursing homes • Hospice care (end-of-life care) • Long term, psychiatric, and specialty hospitals • Community mental health centers • Discuss important healthcare issues for older adults • Increasing need for assistance with daily activities • Financial, legal, ethical issues Introduction to Healthcare and Public Health in the US Delivering Healthcare (part 1) Lecture d

4. School-Based Health Centers • Children can and should receive physical and behavioral healthcare in school • Providers are nurses, physicians, social workers, substance abuse counselors, other providers • Further medical or hospital services are arranged as needed • Parental consent is required • Healthcare may be periodic (for example, mobile health center) or off-site (health center serving more than one school) Introduction to Healthcare and Public Health in the US Delivering Healthcare (part 1) Lecture d

5. The Aging Population 1.5 Chart: (http://www.nia.nih.gov/ResearchInformation/ConferencesAndMeetings/WorkshopReport/Introduction.htm, ND) Introduction to Healthcare and Public Health in the US Delivering Healthcare (part 1) Lecture d

6. Difficulty with ADLs (Activities of Daily Living) by Age Percentage of adults 1.6 Chart: (http://www.aoa.gov/AoARoot/Aging_Statistics/Profile/2010/docs/2010profile.pdf , 2007) Introduction to Healthcare and Public Health in the US Delivering Healthcare (part 1) Lecture d

7. Long term care Facilitiesand Services 1.7 Chart: (http://www.medicare.gov/longtermcare/static/TypesOverview.asp, ND) Introduction to Healthcare and Public Health in the US Delivering Healthcare (part 1) Lecture d

8. Financial and Quality Issues • Centers for Medicare and Medicaid Services (CMS) • Provides health insurance for older adults, disabled, poor • Covers 25% of US population; 94% of people age 65 or older • Reimburses qualifying healthcare facilities • Joint Commission (JC) certifies quality, safety • Independent nonprofit agency • Examines hospitals, nursing homes, home care organizations, mental health programs, etc. • Healthcare facilities volunteer for JC certification • JC accreditation is a major factor in CMS approval for reimbursement Introduction to Healthcare and Public Health in the US Delivering Healthcare (part 1) Lecture d

9. Home Healthcare • Home healthcare is assistance with ADLs and chores inside the home • Family, friends, volunteers may help • Community services may be available • Skilled nursing is needed for medical issues • May be reimbursed by Medicare • Home healthcare agency is another option • Professional service • May be reimbursed by Medicare • Includes hospice care (end-of-life care) Introduction to Healthcare and Public Health in the US Delivering Healthcare (part 1) Lecture d

10. Board and Care Homes(Group Homes) • Group living arrangements for people who cannot live alone and need help with ADLs • Residents may have physical or mental disability, cognitive impairment, substance abuse • Residents may be elderly, but not necessarily • Meals are provided, but medical care is not • Services, quality, and fees vary widely • May be paid in part by private insurance, Medicare/Medicaid, other assistance Introduction to Healthcare and Public Health in the US Delivering Healthcare (part 1) Lecture d

11. Assisted Living • Person has own room or apartment in a large complex • Receives assistance with ADLs, 24-hour care • Offers group dining, social/recreational activities, housekeeping/laundry • Medical services may be available on site • Service plan for each resident evolves over time • Facilities are licensed in most states • Billing is monthly rent plus fees for extra services • Insurance may cover some costs; Medicare does not Introduction to Healthcare and Public Health in the US Delivering Healthcare (part 1) Lecture d

12. Continuing CareRetirement Communities • Offer different types of housing, depending on the level of assistance needed • Separate homes/apartments for independent living • Assisted living facility for help with ADLs • Nursing home on site • May be accredited or not • Billing is a large entry fee plus monthly payments Introduction to Healthcare and Public Health in the US Delivering Healthcare (part 1) Lecture d

13. Nursing Homes • Care for people who cannot live in home or community • May have medical, physical, mental problems • Facilities help with ADLs, provide nursing care • Some homes are hospital-like, others are home-like (for example, have kitchen facilities and social activities) • Services include medical, nursing, personal care • A physician draws up a plan of care • Nursing care pertains to routine medications, acute conditions, rehabilitation, special care units • Facility should be licensed/accredited, although Medicare usually does not pay Introduction to Healthcare and Public Health in the US Delivering Healthcare (part 1) Lecture d

14. Other Long Term CareOptions for Older Adults • Community-based services • Various programs, coordinated by state agencies • State Medicaid may help with costs • In-law apartments • Defined as a separate living space on a property • Subject to local and state laws • Subsidized housing • Provide residence for older adults/disabled/poor, other services • Federal or state agency funds the program • Billing is a percentage of monthly income Introduction to Healthcare and Public Health in the US Delivering Healthcare (part 1) Lecture d

15. Hospice Care • Intended for patients with a terminal illness • Focus is palliative, or comfort care • Care is provided at home, dedicated hospice facility, hospital, assisted living facility, or nursing home • Services may include medical/nursing care, medical equipment, counseling, social services, help with ADLs and housework, respite care • Home care workers should be licensed/bonded • Contact with family is an important focus Introduction to Healthcare and Public Health in the US Delivering Healthcare (part 1) Lecture d

16. Legal and Ethical Issues • Patients may/may not be able to make decisions • Family may not be available; patient may need legal guardian • Patient has right to participate in important decisions • Long term care options • Informed consent • Informed refusal • Advance directives, living wills • Do-not-resuscitate order (DNR), termination of treatment • Power of attorney for healthcare • Long term care facilities have ethical/legal obligations Introduction to Healthcare and Public Health in the US Delivering Healthcare (part 1) Lecture d

17. Long Term Hospitals • Acute-care hospitals that provide prolonged care (for more than 25 days) • Patients may have complex medical problems • May come from intensive care units • May have more than one condition • May need rehabilitation • Medicare covers hospital stay if hospital is certified Introduction to Healthcare and Public Health in the US Delivering Healthcare (part 1) Lecture d

18. Specialty Hospitals, Rehabilitation Care • Specialty hospitals focus on particular diseases or medical fields • Common examples are cardiology, orthopedics, women’s health, and surgery • Less common example: end-stage kidney disease • Rehabilitation hospitals • Stand-alone hospitals or units within a hospital • Provide intensive daily rehabilitation • Outpatient rehabilitation is also available through agencies, clinics Introduction to Healthcare and Public Health in the US Delivering Healthcare (part 1) Lecture d

19. Psychiatric Hospitals • Psychiatric care has evolved • Hospitalization is voluntary in most cases • Many types of care exist • Open units • Crisis stabilization units • Medium-term units • Juvenile wards • Long term care psychiatric hospitals • Some psychiatric hospitals specialize in certain illnesses or addictions Introduction to Healthcare and Public Health in the US Delivering Healthcare (part 1) Lecture d

20. Day Hospitals • Provide mental health treatment during the day • Patient goes home at night • Considered an alternative to outpatient care • Distinct from hospitalization, residential treatment, and day care • Patients are adults or children • Most facilities are hospitals or community centers • Provide individual/group therapy, other treatments • Goal is for patient to function within community Introduction to Healthcare and Public Health in the US Delivering Healthcare (part 1) Lecture d

21. Community MentalHealth Centers • Provide treatment for elderly, adults, or children • Patients have chronic mental illness or recent hospital discharge • Services include outpatient care, emergency care, partial hospitalization, rehabilitation • May be reimbursed by Medicare Introduction to Healthcare and Public Health in the US Delivering Healthcare (part 1) Lecture d

22. Substance AbuseTreatment Centers • Help patients overcome drug and/or alcohol abuse • Various facilities • Residential treatment centers • Outpatient programs • Hospitals • Programs may specialize • By drug (for example, cocaine addiction) • By age group (for example, adolescents) Introduction to Healthcare and Public Health in the US Delivering Healthcare (part 1) Lecture d

23. Delivering Healthcare (Part 1) Summary – Lecture d • Multiple healthcare options exist for medical, mental health, substance abuse, and end-of-life issues • Care location can be school, home, community, hospital • Large variation exists in services, quality, costs • Facilities may or may not be licensed/certified • Services may or may not be reimbursed by Medicare/Medicaid • Complex financial, legal, ethical issues apply • Need for elder care will only grow in the future Introduction to Healthcare and Public Health in the US Delivering Healthcare (part 1) Lecture d

24. Delivering Healthcare (Part 1)Summary • Described the organization of healthcare at the federal, state and local levels (Lecture a) • Described the organization of the VA system and Military Health System (Lecture b) • Described the structure and function of hospital clinical and administrative units (Lecture c) • Described different types of long term care facilities, with an emphasis on their function (Lecture d) Introduction to Healthcare and Public Health in the US Delivering Healthcare (part 1) Lecture d

25. Delivering Healthcare (part 1)References – Lecture d References Administration on Aging. A profile of older Americans: 2010. http://www.aoa.gov/AoARoot/Aging_Statistics/Profile/2010/docs/2010profile.pdf. Accessed April 12, 2011. American Health Care Association, National Center for Assisted Living. Consumer information about long term care. http://www.longtermcareliving.com/assess/index.htm. Accessed April 11, 2011. American Hospital Association. Long term acute care hospitals. http://www.aha.org/aha_app/issues/Medicare/Long-Term-Care-Hospitals/index.jsp. Accessed April 11, 2011. Centers for Medicare & Medicaid Services. https://www.cms.gov. Accessed April 11, 2011. Commission on Accreditation of Rehabilitation Facilities International. Who we are. http://www.carf.org/About/WhoWeAre. Accessed April 11, 2011. Dubler NN. Legal and ethical issues. In: The Merck Manual of Geriatrics. Whitehouse Station, NJ: Merck & Co., Inc.; 2009-2010. http://www.merckmanuals.com/mm_geriatrics/sec1/ch14.htm. Accessed April 12, 2011. Hospital.com. Choosing a long-term psychiatric hospital. http://www.hospital.com/psychiatry.html. Accessed April 11, 2011. Medicare.gov. Types of long-term care. http://www.medicare.gov/longtermcare/static/TypesOverview.asp. Updated March 25, 2009. Accessed April 11, 2011. MedlinePlus. Health system. http://www.nlm.nih.gov/medlineplus/healthsystem.html. Updated May 21, 2010. Accessed April 11, 2011. Introduction to Healthcare and Public Health in the US Delivering Healthcare (part 1) Lecture d

26. Delivering Healthcare (part 1)References – Lecture d (continued) References (continued) National Assembly on School-Based Health Care. http://www.nasbhc.org/site/c.jsJPKWPFJrH/b.2554077/k.BEE7/Home.htm. Accessed April 11, 2011. National Association for Home Care & Hospice. Basic statistics about home care. http://www.nahc.org/facts/10HC_Stats.pdf. Updated 2010. Accessed April 11, 2011. Office of Disability, Aging and Long-Term Care Policy. Licensed board and care homes: preliminary findings from the 1991 National Health Provider Inventory. http://aspe.hhs.gov/daltcp/reports/1993/rn06.htm. Published May 1993. Accessed April 11, 2011. Pace B. Hospice care. JAMA. 2006;295(6):712. The Joint Commission. http://www.jointcommission.org. Accessed April 11, 2011. U.S. General Accounting Office. Specialty hospitals: geographic location, services provided, and financial performance. http://www.gao.gov/new.items/d04167.pdf. Published October 2003. Accessed April 11, 2011. U.S. National Institutes of Health. National Institute on Aging. Workshop report. http://www.nia.nih.gov/ResearchInformation/ConferencesAndMeetings/WorkshopReport/Introduction.htm. Updated August 6, 2009. Accessed April 11, 2011. Wiener JM, Hanley RJ, Clark R, Van Nostrand JF. Measuring the activities of daily living: comparisons across national surveys. Office of Disability, Aging and Long-Term Care Policy. March 9, 1990. http://aspe.hhs.gov/daltcp/reports/meacmpes.htm. Accessed April 11, 2011. Introduction to Healthcare and Public Health in the US Delivering Healthcare (part 1) Lecture d

27. Delivering Healthcare (part 1)References – Lecture d (continued) Charts, Tables, Figures 1.5 Chart: The US Population Aging 65 years and Older from 1990 to 2050. From the US Census Bureauum, Population Projections of the US by Age, Race, and Hispanic Origin: 1993 - 2050, pp 25-1104, 1993. Available from http://www.nia.nih.gov/ResearchInformation/ConferencesAndMeetings/WorkshopReport/Introduction.htm 1.6 Chart: Bar chart depicting the percent of people with limitations in activities of daily living (ADL) by age group; 2007. Available from http://www.aoa.gov/AoARoot/Aging_Statistics/Profile/2010/docs/2010profile.pdf 1.7 Chart: Available from http://www.medicare.gov/longtermcare/static/TypesOverview.asp Introduction to Healthcare and Public Health in the US Delivering Healthcare (part 1) Lecture d