Pharmacy Services & Healthcare History

Settings for Health Care Delivery

• Health care occurs in diverse settings, distinguished by inpatient or ambulatory care.
• Inpatient care involves overnight stays, while ambulatory care does not

Introduction

• Health care is delivered in various settings, self-care or provided by a professional.
• It can be at home or outside, where patients have overnight (inpatient) care or return home (outpatient/ambulatory care).
• Modern Western health care differs from the past, medical science is in the Scientific Revolution
• Settings evolve with changing needs or shed status as preferred sites of care.
• Specialization, staffing, technology, & treatments distinguish newer settings.

Physician Home Visits

• Physician home visits were common, about 40% of physician visits occurring in patient homes in the 1940s
• Visits decreased to less than 1% by the 1980s due to economic efficiency, equipment access, and clinical staff needs.
• Home visits have been revived to increase patient access, especially for those with limited mobility
• Technological advancements now allow for the use of portable medical equipment

Medical Treatment

• New treatments evolve care sites from one place to another
• Hepatitis C led to liver transplants in advanced acute care hospitals
• Discovery of the virus allowed curative antiviral agents to be taken at home
• Public health efforts could eradicate hepatitis C, as smallpox was eradicated in the 20th century.
• Care settings may evolve, but facilities adapt to medical science.
• There aren't absolute definitions for U.S. healthcare, but rather a web of definitions developed by stakeholders.
• The Centers for Medicare & Medicaid Services (CMS) has a payment model for “short-term acute hospitals.”
• Requirements for hospitals vary by state, federal programs.

US Health Care System

• The U.S. health care system has rich delivery settings and providers
• CMS defines 13 major provider types, over 50 places of service, over 100 provider/supplier types, & over 500 provider taxonomies.
• Vertical and horizontal integration across care is important
• Trend toward horizontal consolidation in the 1990s
• Integrated systems are horizontal and vertical since the 2000s
• They may have multiple hospitals, clinics, long-term care, physician practices, and hospices.

Referral Hierarchy

• Referral hierarchy refers to primary, secondary, tertiary, and quaternary care levels.

Primary Care

• The World Health Organization (WHO) has a broad view, not tied to one health profession:
  • Primary Health Care is a society approach to health.
  • Aims to maximize the level and distribution of health, focusing on needs and preferences.
  • Continuum from health promotion to treatment, rehabilitation, and palliative care, close to everyday settings.
• The American Academy of Family Physicians (AAFP) outlines roles
  • includes lowering costs, first contact, "undifferentiated patients," general evaluation, & prevention.
  • Integrated, accessible services by physicians and teams, addressing needs, partnerships, & community.
  • Care is person-centered, team-based, community-aligned, better health, better care, and lower costs.
• Trained in first contact and continuing care for patients with any undiagnosed sign or symptom, not limited by origin, organ, or diagnosis.
  • Includes health promotion, prevention, maintenance, counseling, education, diagnosis, & treatment in settings.

Secondary Care

• The Medical Subject Headings (MeSH) defines secondary care as “specialized healthcare delivered as a follow-up."
• Secondary care typically encompasses care from office visits to specialists to hospital care.

Tertiary Care

• Tertiary care is provided at facilities with subspecialty expertise for referrals.
• It includes complex procedures like open-heart surgery & reconstructive surgery.
• Often in major teaching/academic centers in urban areas with populations.

Quaternary Care

• Quaternary care refers to leading-edge medicine like clinical research protocols.
• Heart, lung transplants, a small fraction of hospitals like NIH Clinical Center and Rockefeller.
• Provided at hospitals and medical centers that also offer routine and tertiary care.
• Attributes are highlighted, but not definitive
• First contact doesn't define primary care, a multi-dimensional view

Primary Care Characteristics

• If primary is about the first contact, it narrows to entry point.
• This meaning is only a triage function.
• If primary means chief, principal, or main, it better understood.
• This supports the multidimensional view of primary care.
• The chapter describes settings for health care delivery, description, problems, and visits.
• These sites are: the home, ambulatory sites, acute care hospitals, and postacute care sites

The Home

• Home includes self & family care, including wellness & fitness to maintain health and slaving illness.
• Hospital is seen as the flagship of the health care system, largest category of National Health Expenditures and popular TV show setting
• Vast majority of people will not receive inpatient acute care.
• People decide whether to access it - 80%-95% of problems are never professionally consulted

Self-Care

• A "take-no-action," “wait-and-see,” or self-medication approach.
• Fevers, headaches, indigestion: common ailments using nonprescription or “over-the-counter" medicines.

Consensus Definition of Self-Care

• Self-Care refers to actions to promote health, prevent disease, limit illness, and restore health.
• Activities are undertaken without professional help, informed by technical knowledge
• Generic attribute: nonprofessional, nonbureaucratic, nonindustrial.
• Individuals decide to become patients after self-diagnosis & advice from friends/family.
• Home is the most common setting for self/family-care
• Last 20 years: rise of “Dr. Google” for inquiries about health.
• Advanced apps and at-home diagnostics expanded range.
• From 2020, there were over 350,000 health apps
• Consumer disease management was 4%.
• Laboratory companies allow consumers to order fertility, blood iron, & cancer tests and collect specimens themselves.

Health Professional Care in the Home

• Home visits, thought relegated, can be a convenient tool to improve access
• Technology allows complex exams, economics are challenging with salaries, and long travels.

Telehealth/Telemedicine

• As a hybrid, telemedicine is practical and affordable with declining costs and increased computer and network performance.
• Providers offer to diagnose patients needing no exam.
• Technology companies adapted to telemedicine in software
• 1964: University of Nebraska demonstrated for psychiatric treatment
• COVID : accelerated, rising to outpatient visits in 2020.
• Telemedicine volumes stabilized in 2021 at pre-pandemic levels.
• Shift in behavioral health, use patterns show small, affluent segment adoption.

Remote Patient Monitoring

• The American Medical Association (AMA) defines remote patient monitoring (RPM)
  • captures patient physiologic data outside a traditional health care location.
  • provides visibility into patients' lives, timely diagnosis and management.
  • Engaging patients through access to data.
• Data collected, transferred to providers, managed, readings can be flagged
• USDepartment of Health and Human Services (DHHS) states monitoring lets providers manage, reducing travel and infection risk

Popular conditions for RPM

• high blood pressure
• diabetes
• weight loss or gain
• heart conditions
• chronic obstructive pulmonary disease
• sleep apnea
• asthma

Common Devices for RPM

• weight scales
• pulse oximeters
• blood glucose meters
• blood pressure monitors
• RPM began in the 1960s.
• NASA's was used to monitor astronauts in real time. COVID pandemic saw used to monitor + people, but adoption has been limited. Seven nurses managed 1,000 sick patients 24/7, admitting those with escalating symptoms. Potential disadvantage: preoccupation with measurement and increased anxiety. More generally, patients need reliable information and healthcare provider collaboration for self-care. In hypertension, the self-measurement of BP on its own failed to lower BP. 70.6 million U.S. patients, or 26.2% of the population, will use RPM tools by 2025. Medicare beneficiaries cost $2,270 (2021 dollars) per year.

Ambulatory Care

• Ambulatory care refers to medical services without overnight stay.
• Examples include outpatient clinics, radiology centers, infusion, surgery centers, freestanding EDs
• Also called outpatient ambulatory or freestanding - improve access , efficiency and experience
• Provided in physician offices, followed by EDs and hospital clinics
• Physician and specialty offices use these facilities

Physician Office

• Physician office is among the oldest sites of care.
• CMS defines office: "a Professional routinely provides examinations, diagnosis, ambulatory basis" additionally a walk in is also considered
• An urgent car facility helps diagnose but are distinct from the physician office.
• Among noninstitutionalized: Visits totaled 948 million in 2021, up from million from 2020 and down from and 2018
• Visits also see to nonphysicians, about both number and ratio to physician visits.
• to physicians with primary care, of visits were for check-ups - to a specific condition.

Physician Visits

• Most is lab tests, followed by prescriptions.
• The vast of these include for patients
• Under new, preventatitve
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• Physician oversee or practice alternative
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• Treats, unscheduled attention/facilities/
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This quiz covers pharmacy services, their impact on patient care, and key moments in healthcare history. Topics include medication optimization, hypertension management, and the evolution of hospitals.