NAVIGATING THE COMPLEX HEALTH SYSTEM

1. NAVIGATING THE COMPLEX HEALTH SYSTEM A Primer for The Nurse

2. PURPOSE OF THIS MODULE To increase your understanding of how knowledge of the health system will help you, the nurse, provides patient-centered care to guide each patient toward desired health outcomes.

3. WHAT IS A COMPLEX SYSTEM • A complex system is a system composed of interconnected parts that as a whole exhibit one or more properties (behavior among the possible properties) not obvious from the properties of the individual parts

4. WHAT ARE SILOS • The American healthcare system … isn’t. It isn’t a “system.” Patients have multiple providers. These providers rarely interact. The payment system operates in silos. And patient care isn’t coordinated. http://blogs.ajc.com/health-flock/2012/12/05/breaking-down-healthcare-silos-the-need-of-healthcare-integration/ SILOS SYSTEM

5. SCOPE OF NURSES’ IMPACT • ND population in 2012 est. 720,000 individuals • 2014 est. 723,500 individuals • 2012 Documented Patient Visits = 3,796,327 • Medical Clinics - Hospital-based only 3,679,739 • Hospital admissions 97,028 • Nursing Facility residents 12,213 • Basic Care residents 4,152 • Assisted Living Facility residents 3,195 • Reports were not found for any of the other provider types or practitioners

6. HEALTH CARE EXPENDITUREShttp://www.cms.gov/mmrr/Downloads/MMRR2011_001_04_A03-.pdf

7. OBJECTIVES • Review the health care system’s provider types and levels of service, regulation, and reimbursement mechanisms; • Investigate your organization’s structure and processes; • Describe your position/role within the organizational structure; and • Demonstrate your knowledge of the health care system to help a patient (and family) consider and access viable options for achieving personally desired health outcomes.

8. PROVIDERS/PRACTITIONERS • Independent Practitioners • Physicians • Dentists • Advance Practice Nurses • Chiropractors • Psychologists • Physical Therapists • Dietitians • Pharmacists • Etc. • Provider Types • Community Agencies • Outpatient Providers • Inpatient Providers • In-Home Providers • Service Types • Preventive • Acute • Rehabilitative • Long Term Care • End of Life

9. THE REGULATION OF HEALTH CARE • Licensure – State • Certification – Federal --Medicare/Medicaid • Accreditation - The Joint Commission, Etc. REIMBURSEMENT FOR HEALTH SERVICES • Private Health Insurance (Much Based On Medicare) • Private Self Pay • Medicare • Medicaid • Population Based - VAMC, IHS, Migrant Health, PHS

10. ORGANIZATIONAL CHART • Visual representation of how a firm intends authority, responsibility, and information to flow within its formal organizational structure. It usually depicts different management functions (finance, human resources, marketing, nursing, environment,) and their subdivisions as boxes linked with lines along which decision making power travels downwards and answerability travels upwards.http://www.businessdictionary.com/definition/organization-chart.html

12. WHY CARE COORDINATION? • Patients and families hate it that we can’t make this work • Poor hand-offs lead to delays, lapses in care, adverse drug effects, and other situations that may be dangerous to health • Ensure transfer of correct information • Provide patient support to wellness • Track referrals & help resolve problems • Less waste • Enormous waste is associated with duplicate testing, unnecessary referrals, unwanted specialist-to-specialist referrals, and failed transitions from hospitals, EDs, & nursing homes. • Clinical practice will be more rewarding • Fewer problems – for patient and for health system • Improve the health of the population • Encourage personal responsibility for health status

13. ELEMENTS OF HANDOFF OF CARE • An established “system” for change in responsibility for patient care • Accurate and complete documentation • Patient Identification, Diagnoses, Events, Anticipated Outcomes • Patient education and understanding • Verbal Communication • Verification of available resources • Shared Responsibility (for the Patient)

14. THE NURSE PULLS IT ALL TOGETHER

15. To earn your certificate of achievement in leadership development you will need to submit the following for Navigating the Complex Health System module: • Describe your employer organization using the outline provided • Define your present position within the employer organization. • Perform and document a successful patient handoff noting the following: • 1. The patient’s desired health outcome • 2. Assessment of each of the listed barriers • 3. Indivisuals/agencies involve in thehandoff (remember the patient). • 4. Elements of the handoff (documents, other communication, transportation, etc.) • 5. Results (2 weeks after the fact) of the handoff.

16. WRAP-UP • Reflect on the complexity of the overall healthcare system • Reflect on your organization within the system • Reflect on your position within your organization • Reflect on the result of your patient advocacy experience • How could a different reality make your experience more successful and satisfying? • What will you do to move toward that different reality? And so we move into the Change & Innovation Module