Primary Care of the Family Reading Notes - PDF

PRIMARY CARE OF THE FAMILY READING NOTES for units one and two: Chapters 1,2, 4, 5, 85, 86, 88 CHAPTER ONE: Scope of practice is not consistent across the states Three themes for future success: The need for nurses to play a full role in practice, education, and leadership The need for diversit...

PRIMARY CARE OF THE FAMILY READING NOTES for units one and two: Chapters 1,2, 4, 5, 85, 86, 88 CHAPTER ONE: Scope of practice is not consistent across the states Three themes for future success: The need for nurses to play a full role in practice, education, and leadership The need for diversity in the nursing workforce The need for better data to evaluate progress Healthy People 2030 needs a lot of work Primary care is defined as: continuous, person centered, relationship based care that considers the needs and preferences of individuals, families, and communities Core competencies for APRNS: Domain 1: Knowledge for Nursing Practice Domain 2: Person-Centered Care Domain 3: Population Health Domain 4: Scholarship for Nursing Practice Domain 5: Quality and Safety Domain 6: Interprofessional Partnerships Domain 7: Systems-Based Practice Domain 8: Information and Healthcare Technologies Domain 9: Professionalism Domain 10: Personal, Professional, and Leadership Development CHAPTER TWO: The APRN role is grounded in the knowledge of skills and caring CARING The intentional and authentic presence of the nurse with another person who is living, caring. In nursing, caring directly characterizes a nurse's knowledge base and service. Generalized patterns of nursing care are represented in the CIRCLE OF CARING MODEL: Courage Authentic presence Advocacy Knowing Commitment Patience CHAPTER FIVE Elements of the diagnostic process: Onset -- duration, characteristics Location -- aggravating factors, relieving factors, treatment Reimbursement Payment standards in the United States are driven by insurance companies, particularly those that administer Medicare and Medicaid. APRNs have made great strides in this area and now receive third-party reimbursement in most settings. In managed care contracts, sometimes called advantage plans, providers, whether APRNs or physicians, are paid a fixed, predetermined rate. Payment by private insurance companies is contract specific and varies with each state's insurance commission. **Reimbursement has long been a controversial issue. Medicare and some other insurance companies reimburse NPs at 85% of physician rates, even though they provide the same services as physicians. This is called "incident to" billing**, indicating that the care was provided incident to the supervising physician's care. Incident to billing allows for services to be paid to the supervising physician for 100% of the charged amount rather than 85%, which an independent NP would be paid. Although incident to billing is advantageous for practices, it isn't for NPs. This form of billing suggests that NP care is not the same quality as physician care, but many patients would disagree. Incident to billing also suggests a hierarchical approach to care rather than a team approach, suggesting that NPs need physician oversight, which is not the case. From a national standpoint, incident to billing makes NP care invisible because all services are billed under physicians' NPI numbers rather than the NPs' numbers who provide the services. Because NPI numbers are used to collect data regarding services provided, it is difficult for Medicare to identify and support all clinicians providing primary care services. In 2019, the Medicare Payment Advisory Commission (MedPAC) suggested doing away with incident to billing to create a more unified system (LaPointe, 2019). Other organizations, such as the AANP, support this recommendation and are working politically to remove this barrier to NP full practice authority and access to care for all persons. THIRD-PARTY PAYER RULES Whether NPs are employed by a hospital, a medical practice, a community health center (such as federally qualified health centers \[FQHCs\]), or are self-employed, a third-party payer most often determines reimbursement policies. Third-party payers fall into seven general categories: 1\. Medicare -- A, B, C (Medicare Advantage Plans), D 2\. Medicaid 3\. Indemnity insurance companies 4\. Managed care organizations (MCOs) 5\. Workers' compensation (WC) 6\. Veterans Administration 7\. Auto liability In addition to these third-party payers, there are patients without health insurance, some who have strong financial assets that allow them to pay out of pocket, but most (the uninsured) do not. These patients are considered private pay. Each payer source has its own policies and fee schedules. All, however, use the Centers for Medicare and Medicaid Services (CMS) guidelines as a foundation. CMS works to make sure that the beneficiaries in its government-funded programs can obtain high-quality health care. In response to rising health-care costs, CMS enacted the Balanced Budget Act of 1997 and gave billing approval for nonphysician practitioners, including NPs. MCOs were slow to add NPs as providers. Over time, these carriers have had a growing number of NPs credentialed as providers. Payments were based on the CMS billing rules (85% of the fee schedule rate) or providers who do not credential NPs may instruct NPs to bill under the physician's provider number. Medicare is a health insurance program for people 65 and older that has four parts: Part A, Part B, Part C, and Part D:  - - - - Medicare A---Hospital Inpatient Services Health-care providers wishing to bill Medicare can join the program by applying online at the Provider Enrollment Chain and Ownership System (PECOS) or by a using the traditional paper form (CMS-855I). Each Medicare provider is assigned a National Provider Identifier (NPI) for billing that must be used in Health Insurance Portability and Accountability Act (HIPAA) transactions. Medicare providers agree to take assignments (accept the CMS-approved amount for health services as full payment) when performing services according to current Medicare physician fee schedules and guidelines. Providers are required to submit a claim (bill) to CMS for all services (covered and uncovered) and will be paid, based on the claim for specified services. The NP's scope of practice, prescriptive authority, and requirement of physician collaboration are designated by state legislation. Each state gives authority to the nurse licensing board to regulate APRNs. In 2021, the Medicare Part A (hospital services) deductible was \$1,484, and premiums were based on the quarters of lifetime work in which Medicare taxes are paid. Medicare A out-of-pocket expense was determined by the deductible rate and limits on what is covered. In 2021, out-of-pocket hospital fees was charged as follows: Hospital stays of 1 to 60 days: no additional payment in each benefit period Days 61 to 90: \$371 per day coinsurance Days 91 and beyond: \$742 coinsurance per "lifetime reserved day" used. After 90 days for each benefit period, the beneficiary can use up to 60 days over their lifetime. Beyond lifetime reserve days: All costs paid by the patient (CMS, 2020e; Medicareworld, 2021) Postacute care for beneficiaries who are responsible for a \$185.50 per day copayment---days 21 to 100 in a skilled nursing facility (SNF). Days 1 to 20 have no out-of-pocket post discharge for acute hospital care. Medicare B---Physician Services CMS payment policy for calendar year 2021 (CY 2021) was based on the annual physician and nonphysician provider fee schedule (Medicare Physician Fee Schedule \[PFS\]) (CMS, 2020e). Comments for the fee schedule were placed in the Federal Register on August 4, 2020, and took effect, as they do yearly, on or after January 1, 2021 (CMS, 2020e). The physician fee schedule reflected an administrative strategy aiming to result in "better accessibility, quality, affordability, empowerment, and innovation" (CMS, 2020e, p 1). For CMS-covered physicians, CMS identifies which services will be reimbursed (100% of the physician PFS) and then stipulates that 80% of the allowed rate will be paid by CMS and 20% is the responsibility of the patient. NPs are reimbursed by CMS at 85% of the physician's fee, with the patient still paying a 20% share; NP fees are typically 15% lower than that of physicians (Frakes, 2006). Most patients on the traditional Medicare plan acquire a secondary insurance plan (premium costs vary by patient health status from \$50 to \$300 per month) to cover the 20% patient out-of-pocket expense. In addition to the 20% patient responsibility, Medicare has a yearly deductible. In 2021, the Medicare B (physician/provider and outpatient services) deductible was \$203 per year. Once paid, the patient is charged 20% of the approved Medicare rate for physician office visits and some diagnostic tests. Information about Medicare beneficiary out-of-pocket expenses can be found at the official U.S. government site for Medicare (CMS, 2020e). For all CMS patients, the out-of-pocket patient responsibility payments (copays and deductibles) should be collected before rendering services. This is especially important at the beginning of the calendar year when most Medicare beneficiaries have not yet met their deductible. Patient out-of-pocket payment responsibility should be verified at each medical treatment episode. If these fees are not collected before the services are rendered, they remain the patient's payment responsibility and will require direct patient billing. Patient billing increases the expense to the practice because of the cost and time involved in collecting funds. CMS providers are required to attempt to collect the copayments and deductible patient payments, and best practice recommends providers do so before rendering services. Medicare D---Pharmaceutical Coverage In 2003, Medicare D was added as part of the Medicare Modernization Act, and the donut hole was initially included to encourage patients to be participative consumers aware of drug costs and choices. This program offers prescription drug coverage for drugs not covered under Medicare A or B. The donut hole is a gap in coverage that begins after the person exceeds the initial coverage limit in their plan. In 2021, the initial coverage limit was \$4,120, up from \$4,020 in 2020. ACA legislation planned to eliminate the hole in coverage. When the out-of-pocket expenses reached \$6,350 in 2021, catastrophic coverage was available. After this, the beneficiary paid only 5% of the copay for drugs for the remainder of the year (Healthline, 2019). CMS across the year pays 75% of medication costs; however, the patient must pay premiums, copayments, and deductibles. Beneficiaries can choose a plan that fits their needs and affects their premium rates. Beneficiaries must be enrolled in the Medicare A or Medicare B program, and this is an optional addition to their coverage. Plan selection affects covered medications, and there are many plan options offered to citizens across the United States. Key categories of drugs must be covered by all plan options, such as cancer treatment medications and antidepressant medication (total of six required drug categories). Pharmaceutical costs are substantial for most CMS beneficiaries, and costs have increased yearly. Premium costs per month range from approximately \$12 to \$195 per month. Plan coverage is seen as four parts: (1) deductible phase (pay 100% of drug discount until meet rate; range from \$0 to \$435/year), (2) initial coverage phase (pay copay, with plan paying \$1 for generics on some plans or up to 25%), (3) coverage gap or donut hole (25% of discounted rate of brand drugs), (4) catastrophic phase (5% copay discount rate) (Eligibility Medicare, 2020). ACA plan policy included fully closing the donut hole in 2020; however, the Bipartisan Budget Act of 2018 affected this closure and delayed implementation. Medicare Advantage Plans Medicare Advantage plans offer another way for eligible citizens to obtain Medicare A (hospital) and B (physician) coverage, and these may be called Medicare C or Medicare MA plans. These plans must be approved by CMS and are offered by private insurance companies. Each Medicare MA must offer all required services. They offer all required benefits of Medicare and usually offer additional benefits, such as drug coverage, uncovered eye care, dental care, and lower copayments. Ease of using one plan for covered benefits is attractive to users. Medicare Advantage carriers are paid subsidies per member by CMS for services rendered by their plan. Beneficiaries, however, must use the health providers that participate in these plans. A limit of out-of-pocket yearly expenses for covered services is identified to beneficiaries to avoid concerns of unexpected costs. Medicare Advantage plans were designed on the premise of offering lower costs based on economic efficiencies realized by volume discounts from commercial business relationships. However, problems have been noted with these plans. Because of the high medical utilization of and greater health-care costs incurred by their beneficiaries, many Medicare MA plans have found this market to be less financially viable. In addition, beneficiaries can use noncovered services or out-of-pocket services but at a higher cost. If a plan's payout exceeds the fixed CMS payment they receive annually, the plan incurs a loss, causing many of these carriers to leave this market. Common types of Medicare MA include the following (CMS, 2020b): Health maintenance organization (HMO) plans Preferred provider organization (PPO) plans Private fee-for-service (PFFS) plans Special needs plans (SNPs) Medicaid Medicaid offers medical assistance to individuals and families with low incomes and limited resources, as well as for those with chronic disabilities. Unlike Medicare, it was designed to be jointly funded by both federal and state governments. The federal government assists states in providing medical care to people who meet the program's financial eligibility criteria, including children, pregnant women, parents, seniors (those with dual eligibility on Medicare with Medicaid paying copay and deductibles), and individuals with disabilities. The ACA established the income eligibility method used today, replacing the previous allocation method overseen by Aid to Families with Dependent Children. The ACA determines income eligibility for Medicaid based on the Modified Adjusted Gross Income (MAGI). Citizens who are blind, disabled, or older than 65 years are exempt from meeting the MAGI requirements. Medicaid, together with the Children's Health Insurance Program (CHIP), provided coverage in 2020 to over 72.5 million Americans (Medicaid.gov, 2019; https://Medicaid.gov/Medicaid/eligibility/index.html). Medicaid payments are made directly to the participating providers, who in turn must accept the Medicaid (lower) payment as payment in full. Two exceptions are (1) disproportionate-share hospital payments (hospitals that care for a disproportionate share of Medicaid-eligible patients) and (2) hospice care. Although lawmakers have discussed changing the Medicaid system, with an overarching focus of putting more control in the hands of each state, currently no changes have been made. The federal government matches dollar spending for qualifying mandatory services offered by the individual state. Reimbursement rates must remain sufficient to enlist enough providers willing to perform services and ensure that medical care is available to the general population in the region. In recent years, since the MAGI, citizens have benefited from a reduced delay experienced when seeking enrollment and entering or renewing Medicaid and CHIP (Medicaid.gov, 2020). Guidelines for the Medicaid plan are available at the Medicaid Web site by state and on the Benefits for Medicaid Web site (Medicaid.gov, 2019). There are limitations and criteria for APRN reimbursable services outlined in each state's guidelines that can be located by selecting each state on the ANA Web site (ANA, 2020). There has been an expansion of coverage services for the four APRN roles, as there is a need for practitioner services in the growing physician shortage areas. APRNs are also a cost savings as they are paid at a fraction of the Medicaid PFS. Political opposition to ACA legislation for Medicaid recipients is linked to states' participation in the Medicaid expansion (National Academy for State Health Policy, 2020). On June 28, 2012, the U.S. Supreme Court found that the ACA Medicaid expansion was coercive to the states, ruling that the Department of Health and Human Services (HHS) had no enforcement authority over Medicaid expansion. States could opt not to accept Medicaid expansion funds, which reduced health-care services for Medicaid patient populations in those states. However, this ruling left the health-care coverage and other provisions of the ACA intact. States that did not accept the Medicaid expansion proved to have lower quality of care and reduced access for Medicaid services. Medicaid expansion had a positive financial budget and economic impact in states accepting expansion due to higher federal investment related to this program offering (RWJF, 2019) THIRD-PARTY PAYER RULES Whether NPs are employed by a hospital, a medical practice, a community health center (such as federally qualified health centers \[FQHCs\]), or are self-employed, a third-party payer most often determines reimbursement policies. Third-party payers fall into seven general categories: 1\. Medicare -- A, B, C (Medicare Advantage Plans), D 2\. Medicaid 3\. Indemnity insurance companies 4\. Managed care organizations (MCOs) 5\. Workers' compensation (WC) 6\. Veterans Administration 7\. Auto liability In addition to these third-party payers, there are patients without health insurance, some who have strong financial assets that allow them to pay out of pocket, but most (the uninsured) do not. These patients are considered private pay. Each payer source has its own policies and fee schedules. All, however, use the Centers for Medicare and Medicaid Services (CMS) guidelines as a foundation. CMS works to make sure that the beneficiaries in its government-funded programs can obtain high-quality health care. In response to rising health-care costs, CMS enacted the Balanced Budget Act of 1997 and gave billing approval for nonphysician practitioners, including NPs. MCOs were slow to add NPs as providers. Over time, these carriers have had a growing number of NPs credentialed as providers. Payments were based on the CMS billing rules (85% of the fee schedule rate) or providers who do not credential NPs may instruct NPs to bill under the physician's provider number. Medicare A---Hospital Inpatient Services Health-care providers wishing to bill Medicare can join the program by applying online at the Provider Enrollment Chain and Ownership System (PECOS) or by a using the traditional paper form (CMS-855I). Each Medicare provider is assigned a National Provider Identifier (NPI) for billing that must be used in Health Insurance Portability and Accountability Act (HIPAA) transactions. Medicare providers agree to take assignments (accept the CMS-approved amount for health services as full payment) when performing services according to current Medicare physician fee schedules and guidelines. Providers are required to submit a claim (bill) to CMS for all services (covered and uncovered) and will be paid, based on the claim for specified services. The NP's scope of practice, prescriptive authority, and requirement of physician collaboration are designated by state legislation. Each state gives authority to the nurse licensing board to regulate APRNs. In 2021, the Medicare Part A (hospital services) deductible was \$1,484, and premiums were based on the quarters of lifetime work in which Medicare taxes are paid. Medicare A out-of-pocket expense was determined by the deductible rate and limits on what is covered. In 2021, out-of-pocket hospital fees was charged as follows: Hospital stays of 1 to 60 days: no additional payment in each benefit period Days 61 to 90: \$371 per day coinsurance Days 91 and beyond: \$742 coinsurance per "lifetime reserved day" used. After 90 days for each benefit period, the beneficiary can use up to 60 days over their lifetime. Beyond lifetime reserve days: All costs paid by the patient (CMS, 2020e; Medicareworld, 2021) Postacute care for beneficiaries who are responsible for a \$185.50 per day copayment---days 21 to 100 in a skilled nursing facility (SNF). Days 1 to 20 have no out-of-pocket post discharge for acute hospital care. Medicare B---Physician Services CMS payment policy for calendar year 2021 (CY 2021) was based on the annual physician and nonphysician provider fee schedule (Medicare Physician Fee Schedule \[PFS\]) (CMS, 2020e). Comments for the fee schedule were placed in the Federal Register on August 4, 2020, and took effect, as they do yearly, on or after January 1, 2021 (CMS, 2020e). The physician fee schedule reflected an administrative strategy aiming to result in "better accessibility, quality, affordability, empowerment, and innovation" (CMS, 2020e, p 1). For CMS-covered physicians, CMS identifies which services will be reimbursed (100% of the physician PFS) and then stipulates that 80% of the allowed rate will be paid by CMS and 20% is the responsibility of the patient. NPs are reimbursed by CMS at 85% of the physician's fee, with the patient still paying a 20% share; NP fees are typically 15% lower than that of physicians (Frakes, 2006). Most patients on the traditional Medicare plan acquire a secondary insurance plan (premium costs vary by patient health status from \$50 to \$300 per month) to cover the 20% patient out-of-pocket expense. In addition to the 20% patient responsibility, Medicare has a yearly deductible. In 2021, the Medicare B (physician/provider and outpatient services) deductible was \$203 per year. Once paid, the patient is charged 20% of the approved Medicare rate for physician office visits and some diagnostic tests. Information about Medicare beneficiary out-of-pocket expenses can be found at the official U.S. government site for Medicare (CMS, 2020e). For all CMS patients, the out-of-pocket patient responsibility payments (copays and deductibles) should be collected before rendering services. This is especially important at the beginning of the calendar year when most Medicare beneficiaries have not yet met their deductible. Patient out-of-pocket payment responsibility should be verified at each medical treatment episode. If these fees are not collected before the services are rendered, they remain the patient's payment responsibility and will require direct patient billing. Patient billing increases the expense to the practice because of the cost and time involved in collecting funds. CMS providers are required to attempt to collect the copayments and deductible patient payments, and best practice recommends providers do so before rendering services. Medicare D---Pharmaceutical Coverage In 2003, Medicare D was added as part of the Medicare Modernization Act, and the donut hole was initially included to encourage patients to be participative consumers aware of drug costs and choices. This program offers prescription drug coverage for drugs not covered under Medicare A or B. The donut hole is a gap in coverage that begins after the person exceeds the initial coverage limit in their plan. In 2021, the initial coverage limit was \$4,120, up from \$4,020 in 2020. ACA legislation planned to eliminate the hole in coverage. When the out-of-pocket expenses reached \$6,350 in 2021, catastrophic coverage was available. After this, the beneficiary paid only 5% of the copay for drugs for the remainder of the year (Healthline, 2019). CMS across the year pays 75% of medication costs; however, the patient must pay premiums, copayments, and deductibles. Beneficiaries can choose a plan that fits their needs and affects their premium rates. Beneficiaries must be enrolled in the Medicare A or Medicare B program, and this is an optional addition to their coverage. Plan selection affects covered medications, and there are many plan options offered to citizens across the United States. Key categories of drugs must be covered by all plan options, such as cancer treatment medications and antidepressant medication (total of six required drug categories). Pharmaceutical costs are substantial for most CMS beneficiaries, and costs have increased yearly. Premium costs per month range from approximately \$12 to \$195 per month. Plan coverage is seen as four parts: (1) deductible phase (pay 100% of drug discount until meet rate; range from \$0 to \$435/year), (2) initial coverage phase (pay copay, with plan paying \$1 for generics on some plans or up to 25%), (3) coverage gap or donut hole (25% of discounted rate of brand drugs), (4) catastrophic phase (5% copay discount rate) (Eligibility Medicare, 2020). ACA plan policy included fully closing the donut hole in 2020; however, the Bipartisan Budget Act of 2018 affected this closure and delayed implementation. Medicare Advantage Plans Medicare Advantage plans offer another way for eligible citizens to obtain Medicare A (hospital) and B (physician) coverage, and these may be called Medicare C or Medicare MA plans. These plans must be approved by CMS and are offered by private insurance companies. Each Medicare MA must offer all required services. They offer all required benefits of Medicare and usually offer additional benefits, such as drug coverage, uncovered eye care, dental care, and lower copayments. Ease of using one plan for covered benefits is attractive to users. Medicare Advantage carriers are paid subsidies per member by CMS for services rendered by their plan. Beneficiaries, however, must use the health providers that participate in these plans. A limit of out-of-pocket yearly expenses for covered services is identified to beneficiaries to avoid concerns of unexpected costs. Medicare Advantage plans were designed on the premise of offering lower costs based on economic efficiencies realized by volume discounts from commercial business relationships. However, problems have been noted with these plans. Because of the high medical utilization of and greater health-care costs incurred by their beneficiaries, many Medicare MA plans have found this market to be less financially viable. In addition, beneficiaries can use noncovered services or out-of-pocket services but at a higher cost. If a plan's payout exceeds the fixed CMS payment they receive annually, the plan incurs a loss, causing many of these carriers to leave this market. Common types of Medicare MA include the following (CMS, 2020b): Health maintenance organization (HMO) plans Preferred provider organization (PPO) plans Private fee-for-service (PFFS) plans Special needs plans (SNPs) Medicaid Medicaid offers medical assistance to individuals and families with low incomes and limited resources, as well as for those with chronic disabilities. Unlike Medicare, it was designed to be jointly funded by both federal and state governments. The federal government assists states in providing medical care to people who meet the program's financial eligibility criteria, including children, pregnant women, parents, seniors (those with dual eligibility on Medicare with Medicaid paying copay and deductibles), and individuals with disabilities. The ACA established the income eligibility method used today, replacing the previous allocation method overseen by Aid to Families with Dependent Children. The ACA determines income eligibility for Medicaid based on the Modified Adjusted Gross Income (MAGI). Citizens who are blind, disabled, or older than 65 years are exempt from meeting the MAGI requirements. Medicaid, together with the Children's Health Insurance Program (CHIP), provided coverage in 2020 to over 72.5 million Americans (Medicaid.gov, 2019; https://Medicaid.gov/Medicaid/eligibility/index.html). Medicaid payments are made directly to the participating providers, who in turn must accept the Medicaid (lower) payment as payment in full. Two exceptions are (1) disproportionate-share hospital payments (hospitals that care for a disproportionate share of Medicaid-eligible patients) and (2) hospice care. Although lawmakers have discussed changing the Medicaid system, with an overarching focus of putting more control in the hands of each state, currently no changes have been made. The federal government matches dollar spending for qualifying mandatory services offered by the individual state. Reimbursement rates must remain sufficient to enlist enough providers willing to perform services and ensure that medical care is available to the general population in the region. In recent years, since the MAGI, citizens have benefited from a reduced delay experienced when seeking enrollment and entering or renewing Medicaid and CHIP (Medicaid.gov, 2020). Guidelines for the Medicaid plan are available at the Medicaid Web site by state and on the Benefits for Medicaid Web site (Medicaid.gov, 2019). There are limitations and criteria for APRN reimbursable services outlined in each state's guidelines that can be located by selecting each state on the ANA Web site (ANA, 2020). There has been an expansion of coverage services for the four APRN roles, as there is a need for practitioner services in the growing physician shortage areas. APRNs are also a cost savings as they are paid at a fraction of the Medicaid PFS. Political opposition to ACA legislation for Medicaid recipients is linked to states' participation in the Medicaid expansion (National Academy for State Health Policy, 2020). On June 28, 2012, the U.S. Supreme Court found that the ACA Medicaid expansion was coercive to the states, ruling that the Department of Health and Human Services (HHS) had no enforcement authority over Medicaid expansion. States could opt not to accept Medicaid expansion funds, which reduced health-care services for Medicaid patient populations in those states. However, this ruling left the health-care coverage and other provisions of the ACA intact. States that did not accept the Medicaid expansion proved to have lower quality of care and reduced access for Medicaid services. Medicaid expansion had a positive financial budget and economic impact in states accepting expansion due to higher federal investment related to this program offering (RWJF, 2019) **Health Insurance Portability and Accountability Act (HIPAA)** HIPAA can mean different policy concerns to different people. The act is separated into two parts, Title I and Title II: Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs. Title II addresses administrative simplification and requires the U.S. Department of Health and Human Services to establish national standards for electronic health-care transactions and national identifiers for providers, health plans, and employers. It also addresses the security and privacy of health data. These standards were implemented to improve the efficiency and effectiveness of the nation's health-care system by encouraging the widespread use of electronic data interchange in health care (CMS, 2005). HIPAA legislation is important to the daily management of the practitioner practice setting. This legislation focuses on password management, workstation security, e-mail and Internet use, and facility/physical security. Password protection ensures the privacy of patients' health-care information. With increased mandatory submission of electronic billing files and EMRs, a provider must take added precautions to protect the patient's electronic personal information **PRIMARY PREVENTION**: Immunizations, health education, skin cancer prevention methods, weight control, seat belt use, education on: smoking, alcohol, drugs, protective hearing, nutrition, exercise, stress reduction **SECONDARY PREVENTION:** Screenings -- cancers, diabetes, hypertension, stds, anemia, height, weight, BMI screenings **TERIARY PREVENTION:** Treatment to prevent further sequelae of cardiovascular disease, respiratory disease, etc **Primary, secondary, and tertiary prevention are three levels of health promotion and disease prevention**:  - - - - - - - - - - - - - - POWERPOINT NOTES **PRIMARY CARE IN THE 21^st^ CENTURY - A CIRCLE OF CARING** Florence Nightengale -- 1861, laws of sickness and laws of health Lavinia Dock -- evolved a community health nursing model at beg of 20^th^ century Virginia Henderson -heart, head, hand of nursing -- health happens where people live, love, learn, work, play Standardized nursing protocols -- evolved from the work of early school nurses and NY public health department Martha Rogers -argued for necessity of independent basis of nursing practice where autonomous nursing practice could grow 1990 -- Benners "from novice to expert" used by NONPF to create 5 domains for framwork for primary care NP curricula **2006 -- revised NONPF** -- ***7 domains*** and 75 core competencies that NPs must demonstrate upon graduation: Management of patient health/illness status Teaching/coaching function NP patient relationship Professional role Managing and negotiating health-care delivery systems Monitoring and ensuring the quality of healthcare practice Culturally sensitive care **Swanson**: 1995 Spirit function conceptual model of nursing for the APRN The core of every person is the spirit -- the spirit is an animating or vital principle held to give live to physical organisms **Nursing** is a goal directed interpersonal relationship between the patient and nurse, based on traditional nursing process components such as assessing, planning, intervening, and evaluating Interventions are broad based and range from play, music, and stories to the utilization of counseling principles such as active listening and anticipatory guidance **Shuler's 1993 NP practice model:** Rooted in holistic patient database that includes physical, social, cultural, environmental, and spiritual dimensions The patient's physical and psychological ability to participate in wellness activities is assessed and creative, uninhibited problem-solving and identification of appropriate wellness activities are pursued **Symptom Management 1994:** Symptoms should be reviewed as subjective experiences reflecting changes in a person\'s biophysical function, sensation, or cognition. 3 dimensions The symptom experience (subjective) Symptom management strategies Symptom outcomes **Snyder and Mirr 1995:** Conceptualize advanced practice within a nursing paradigm around human responses as a focus for nursing interventions Self-care limitations Impaired functioning in areas of rest, sleep, ventilation, circulation, nutrition Pain and discomfort Emotional problems related to the illness and treatment, life-threatening events, or daily experiences like anxiety, loss, or loneliness Distortion of symbolic functions reflected in interpersonal and intellectual processes such as hallucinations Deficiencies in decision-making ability to make personal choices Self-image changes required by health status Dysfunctional perceptual orientations to health Strains related to life processes such as birth, development, and death Problematic affiliative relationships **Ryan's 2009 Integrated Theory of Health Behavior Change (ITBHC):** Health promotion activities are an integral part of the long-term health and well-being of both healthy people and those with chronic illnesses APNs are in a position to facilitate and support health behavior changes in their clients and can tailor interventions that can positively affect long-term health status **Cumbie, Conley, and Burman's 2004 model of promoting process engagement:** Client centered theory developed to help APNs managed the care of chronically ill clients Interventions of the APRN are chosen based on each client\'s needs and expectations of their care, are developed in collaboration with the client **Nurse coaching:** Promotes integrative approaches for health and wellbeing Can be used to promote behavioral change Uses motivational interviewing, nonjudgemental acceptance of the patient, the transtheoretical model of behavioral change, appreciative inquiry, cultural perspectives, and "rituals of healing" **Changing Models of Medical Practice and Research:** Contributing factors to re-examination of traditional professional roles Advances in therapeutics, progress of medicine from integrated view of illness and therapeutics to one of discrete diseases with distinct causes and specific therapeutics - Success of this led to physician specialists with narrow focus on human disease and to technologically advanced medical interventions that are removed from day to day lives of patients Some difficulties fulfilling moral and social responsibilities of medicine, realization of limits of medical progress and technological intervention Call for a better balance between cure-oriented and care-oriented medicine **The Circle of Caring:** Broadened and contextualized database, labeling of the patient's concern that incorporates the patient\'s responses to the meaning of illness in his/her day-to-day life Holistic approach to an individualized therapeutic plan that includes nursing interventions based on evidence which can include complementary therapies incorporated with surgical, pharmacologic, and non-pharmacologic interventions The outcomes are viewed based on the patient, family, group, and community perceptions of improvement, as well as the more traditional, quantified outcome measures like mortality and morbidity data This model is a synthesized view of a problem solving methodology for a variety of settings. It is a contextualized approach The phenomenon of human responses as "calls for nursing" This is the HALLMARK of broadened approach to therapeutics and interventions Caring is the CENTRAL concept in nursing and is uniquely known and expressed in nursing, nursing takes place within nursing situations, nursing is a discipline of knowledge and a professional service that's goal is nurturing persons living, caring, and growing in caring Attributes of caring: knowing, patience, authentic presence, commitment, courage, and advocacy Productive tension between healthcare professionals benefits the care of all patients **CARING AND THE ADVANCED PRACTICE NURSE:** Caring is the essence of being human, caring is the essence of nursing ALL human based services are based on caring; nursing is DIFFERENT because caring directly characterizes nursing's knowledge base and services **Medicine** -- in medicine, a fundamental commitment to caring is directing characterized in the DX and RX of human structural and functional problems, usually characterized in physical terms **Generalized patterns of caring**: ***Courage*** -- the human act, daily application of values, ethical grounding for practice, manifests itself in making one's nursing vocation on commitment to these values and beliefs that undergird caring **Authentic presence:** Intentionally being with another in the fullness of ones personhood. The caring initiated through authentic presence is the initiating and sustaining medium of nursing within the nursing situation **Advocacy:** GADOW-EXISTENTIAL ADVOCACY -- self is brought into the situation as a full partner. When the nurse offers existential advocacy, the nurse feels known, respected, and connected in a way that affirms humanity and being **Knowing:** Directly implies being deeply attuned, comes through intentional and authentic presence. There are patterns of knowing: Practitioner draws on personal knowing as essential intuitive knowing Empiric knowing -- avenue for drawing on science and skilled observation Ethical knowing -- prompts consideration of values and morals for situations Esthetic knowing -- incorporation of knowing into a situation for integrated understanding with the nursed **Commitment:** Choosing to be a member of the discipline and profession of nursing speaks to a lifelong commitment of service to humankind Directs obligation or what "ought to be" in a particular situation Conflicts to commitment -- economically driven care might conflict with calls from patients **Patience:** Trusting people to grow at their own pace, in their own way Not a passive attribute -- an active openness to "the moment alive with possibilities" Humility and courage intimately linked to patience -- the courage to let someone "be" and freedom of choice **ELEMENTS OF THE DIAGNOSTIC PROCESS:** **OLD CART** Onset Location Duration Characteristics Aggravating factors Relieving factors Treatment **CSOC** **Chief Compliant** Specific questions -- sort out competing diagnoses Open ended questions Clarify story Address what patient thinks is wrong, establish a relationship, identify with patient what is most important to accomplish **MEDICALHISTORY** Refine hypothesis, suggest risk factors, all medications, immunizations, allergies and kind of reaction, health maintenance practices **FAMILY HISTORY** Part of risk factor assessment, genograms **SOCIAL HISTORY** Work history Functional health patterns **REVIEW OF SYSTEMS (ROS):** Questionnaire -- go from general to specific **FUNCTIONAL HEALTH PATTERNS** Marjory Gordons Nursing questions Advanced assessment **PHYSICAL EXAMINATION** Clarify and detect **DIAGNOSTIC TESTS:** Used to confirm, rule-out, or screen Vary in usefulness -- look at sensitivity -- few false negatives when high sensitivity , specificity -- few false positives when high specificity, and predictive value, look at false-positive and false-negative results, accuracy, cost and convenience **DIFFERENTIAL DIAGNOSIS** Prioritize list of possibilities One approach: "Skin In" -- think of all problems starting with the skin Present patient to preceptors Clarify problem list Decide how to best manage using clinical judgment Brief teaching, counseling **A power of attorney (POA) in healthcare**, also known as a medical power of attorney or health care proxy, is a legal document that allows someone to make medical decisions for you if you are unable to do so. The person you choose to make these decisions for you is called your healthcare agent.  Here are some things to consider about a healthcare POA:  - - - - - **A living will is** a legal document that specifies a person\'s medical treatment preferences if they are unable to make medical decisions. It\'s a type of advance directive that can help ensure a person receives the care they want if they are seriously ill or in a terminal condition.  A living will can include:  - A list of treatments to receive or avoid  - Preferences for organ and tissue donation  - Instructions for feeding tubes, breathing tubes, and dialysis machines  - Where to receive medical care, such as at home, in a nursing home, or another facility  - How nutrition should be provided  - Pain management preferences  When creating a living will, it\'s important to consider specific situations that may arise, such as when a patient is unconscious or in a vegetative state. It\'s also a good idea to discuss the living will with family members so they understand the person\'s wishes.  Living wills can vary by state, and not all states allow them. Some states offer living will registries to make them more accessible to doctors and other health care providers **A health care proxy** is a person who is authorized to make medical decisions for you if you are unable to communicate your wishes. They are also known as a representative, surrogate, or agent.  A health care proxy is a type of advance directive, and is often used in conjunction with a living will. They are important for advance care planning.  A health care proxy can: - Access your medical records - Agree to treatment decisions - Choose between different treatments - Decide whether or not to provide treatment, based on your wishes **ETHICS:** Ethics -- what one ought to do Bioethics -- when the moral choices involves healthcare Dilemma -- a situation where there are several unequally satisfying solutions OR when there is a conflict between one's values NINE provisions in ANAs code of ethics Practice with compassion and respect for the inherent worth, dignity, and personal attributes of every person, without prejudice The nurse's primary commitment is to the patient, whether an individual, family, group, community, or population The nurse promotes, advocates for, and protects the rights, health, and safety of the patient The nurse has authority, accountability, and responsibility for nursing practice, makes decisions, and takes action consistent with the obligation to provide optimal care The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth The nurse, through individual and collective action, establishes, maintains, and improves the moral environment of the work setting and the conditions of employment, conducive to quality health care The nurse, whether in research, practice, education, or administration, contributes to the advancement of the profession The nurse collaborates with other health professionals and the public to protect and promote human rights, health diplomacy, and health initiatives The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy **Deontology** - also known as duty-based ethics, is an ethical theory that is often used in healthcare to distinguish right from wrong by following a set of rules. Deontology is based on the idea that some actions are morally right or wrong regardless of the consequence IMMANUAL KANT **Universalizability** is an ethical principle that states that moral judgments should be equally applicable to all relevantly identical situations. It is also a principle of Immanuel Kant\'s categorical imperative, which states that one should only act in ways that they would want to become universal law **TELEOLOGY** is the idea that ethical actions are directed toward achieving a specific goal, and that the morality of an action is determined by its outcome. The term \"teleological\" comes from the Greek words telos, meaning \"end\" or \"goal\", and logos, meaning \"science\".  Teleological ethics is also known as consequentialist ethics, and it\'s often contrasted with deontological ethics, which holds that the morality of an action is independent of its outcome.  The greatest amount of happiness and the least amount of harm Some examples of teleological theories include: - A modern teleological theory that defines right conduct as that which promotes the best consequences JOHN STUART MILL **ETHICAL PRINCIPLES:** **Autonomy --** self-determination, respect for all persons, competence, informed consent **Beneficence** -- Requires positive action, balancing of harm vs benefits, principle of proportionality, example -- caring for a very contagious patient **Nonmalfeficence --** Do no harm, the foundation of healthcare, does NOT require taking positive action, **Veracity** -- Truth telling **Confidentiality** -- respect for privileged information **Fidelity** -- Keep promises, avoid false expectations **Justice** -- fairness **Established expectations for APRNS:** LACE -- licensure, accreditation, certification, education **REIMBURSMENT** -- unequal pay for APRNS - Medicare - Medicaid **MALPRACTICE -- Must have:** Duty to patient Must deviate from standard of care Harm or damages must occur as a result **Claims based policy** -- covers claims only if incident occurred when the NP paid the premium and only if still enrolled with same insurance carrier Tail coverage -- covers claims that may be filed that occurred while employed and insured even if retired **Occurrence based policy** -- if claim is filed against NP in the future, it is covered if an occurrence based policy was in effect at the time the incident occurred. \*\*\*BEST COVERAGE **SCOPE OF PRACTICE:** FULL PRACTICE -- NPs can evaluate and diagnose patients, manage treatments, prescribe including controlled substances COLLABORATIVE PRACTICE -- written statement that defines the joint practice of an MD and an APRN in a collaborative and complementary working relationship Provides mechanism for legal protection of the APRN and sets out the rights and responsibilities of each party involved RESTRICTIVE PRACTICE -- NPs ability to practice is restricted in at least one element of the NP practice, state law requires career long supervision, delegation, or team management by another health provider in order for the NP to provide patient care**\ ** The **Affordable Care Act (ACA)** has had a significant impact on Advanced Practice Registered Nurses (APRNs) and the nursing profession in several ways, including:  - 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