Ambulatory And Primary Care - University Of South Florida
Ambulatory and Primary Care1 Presentation ObjectivesoooooDefine ambulatory careDefine primary careExplain subsets of ambulatory careExplain ambulatory care and accreditationChallenges and future of ambulatory care2 What is Ambulatory Care?oDefine ambulatory careoDefine primary careoExplain subsets of ambulatory careoExplain ambulatory care and accreditationoChallenges and future of ambulatory care31
What is Ambulatory care? Personal health care provided toindividuals who are not occupying a bed ina health care institution or in a healthfacility.facility Ambulatory care vs. primary care Follow-up care following inpatientepisodes A contemporaneous shift to ambulatorycare4 Where is Ambulatory Care ServiceProvided?In a variety of settings, including: Freestanding provider offices Hospital-based clinics School-based clinics Public health clinics Community health centers5 Ambulatory Care VisitsNumber of Ambulatory Care ale75 Female6Source: Health United States 2000 (1998 data)2
Physician Office Visit(National Center for Health Statistics. 2006)7 Physician Office Visit(National Center for Health Statistics. 2006)8 Physician Office Visit Data‐1:(National Center for Health Statistics. 2006)Trend of Office Visit by Type of illness and Season93
Ambulatory Care Visits:Physician‐visits by RaceNumber of Ambulatory Visits by Race9080706050403020100ERHospital OutpatientBlackWhitePhysician's OfficeOther10 Annual rate of visits to office‐based physiciansby patient race and ethnicity11(National Center for Health Statistics. 2006) Trends in Ambulatory Care Visit(1980‐1990‐2000)Trends in Ambulatory Care Visits (% of Visits)6050403020100Primary Care VisitsGeneral/Family Practitioner1980Source: US Dept. of HHS 2000Internist1990Pediatrician2000124
Organizationof Ambulatory Care Services Two major categories1. Physicians offices (solo, group, managed care)2. Hospital based ambulatory services–––––ClinicsHospital sponsored group practiceHealth promotion centersFree standing surgical centersEtc 13Composition of total ambulatory care ysician Office83%14 Reasons for physician office visitsWhy do people go to the physician's 68.34.950.71.50ArthritisChronic Obesity2005155
Office visits by phsycian specialty (2005)Source: CDCAll others29%General and familymedicine22%Internal medicine17%Orthopedic surgery5%Ophthalmology6%Obstetrics andgynecology7%Pediatrics14%16 Primary CareoDefine ambulatory careoDefine primary careoExplain subsets of ambulatory careoExplain ambulatory care and accreditationoChallenges and future of ambulatory care17 What is Primary Care?Primary care is the provision of integrated,accessible health care services by professionalswho are accountable for addressing a large majorityof personal health care needs, developing asustained partnership with patientspatients, and practicingin the context of family and community (Institute ofMedicine, 1999) Keywords Community Sustained partnership186
Primary Care Providers The providers of Primary Care fall into fourmajor disciplines: Physicians Nurse Practitioners (NP) Midwives Physician Assistants (PAs)19 Percent of services deliveredby Primary care providersMidwifesNurse practitionersPhysician assistantsPhysicians (95.2%)20 Out Patient Visit: Children under 18217
Out Patient Visit: bypatient age and sex: 2004National Center for Health Statistics. 200622 Out Patient Visit: by patient age: 2004National Center for Health Statistics. 200623 Out Patient Visit: by patient age and sex: 2004National Center for Health Statistics. 2006248
Out Patient Visit:by patient age, race and ethnicity (2004)National Center for Health Statistics. 200625 Out Patient Visit: by source of payment : 2004National Center for Health Statistics. 2006 26Out Patient VisitRising role of midlevel providersNational Center for Health Statistics. 2006279
Subsets of Ambulatory CareoDefine ambulatory careoDefine primary careoExplain subsets of ambulatory careoExplain ambulatory care and accreditationoChallenges and future of ambulatory care28 1. Emergency Care29 Emergency Care Service Definition:– inpatient and outpatient services needed toevaluate or stabilize an emergency medicalcondition An emergency medical condition: one that manifestsitself by acute symptoms of sufficient severity3010
The U.S. Emergency System 911 Response System Hospital based emergency services– Different levels of trauma hospitals– 24/724/ capabilitybili– Over 92.6% of hospitals have an ED Treatment for acutely ill, injured, walk ins Evaluation prior to admission Volume: approximately 100 million31 Emergency care (contd.)oCategories of patients entering through the ER1. Emergent: Patient should be seen in less than 15minutes.2 Urgent:2.Ut PatientP ti t shouldh ld beb seen withinithi 15‐6015 60minutes.3. Semi‐urgent: Patient should be seen within 1‐2hours4. Non‐urgent: Patient should be seen within 24hours.32Categories of patients receiving emergency careUnknown nt22%Urgent38%33National Center for Health Statistics 2000 (1999 data)11
Relevant DevelopmentsEmergency Care Walk‐in units to relieve the volume ofemergency services Financial pressure to divert non‐urgentpatients Pre‐emergency department care34Percent distribution of ambulatory care visits by setting type (2004)Medical specialtyoffices18%Surgical specialtyoffices16%Emergencydepartments10%Primary care offices48%Outpatientdepartments8%353612
What time is it?Average length of time for duration of office visits andemergency department waiting ice visit duration19942004Waiting time in emergency departments37 ER Visit: Seasonal variationin selected reasons by Calendar QuarterNational Center for Health Statistics. 200638 ER Visit: by Age Group : 2004National Center for Health Statistics. 20063913
ER Visit: by Age, Race and Ethnicity : 2004National Center for Health Statistics. 200640 ER Visit: by Primary Source of Payment : 2004National Center for Health Statistics. 200641 ER Visit: by Mean Waiting Time : 2004National Center for Health Statistics. 20064214
2. Subspecialty Care43 Subspecialty Care Definition– Care given by physicians who are not generalists– Ambulatory– Generalists: family medicinemedicine, general pediatricspediatrics,general internal medicine, geriatric medicine, andgeneral OBGYN– Subspecialists: all others Care that is not appropriate in primary care setting Referral through primary or direct contact by patient44From inpatient to ambulatorySurgery Surgeries per 1000 people6050403020100Ambulatory SurgeryInpatient Surgery199419984515
Growth in percentage of outpatientsurgeriesPercent of surgeries performed in ambulatory settings61.754.916.419801993199846 3. Home Health Care47 Home Health Care What is it?– A wide variety of care services provided ordelivered to the patient’s home– Typically ordered by a physician and medicallynecessary– Per visit versus per hour– Who gets it?4816
It can be high tech o Infusion Therapy (IV/pumps)o Home Uterine Monitoringo Ventilator Managemento Heparinepa Therapye apy (a(anti-coagulant)coagu a )o Chemotherapyo Compounding of Drugso Diagnostic Services, Lab/x-ray49 Skilled Professional home healthagency services include:o Nursing provided by a registered nurse (RN),nurse practitioner (NP), or a licensed practicalnurse (LPN).o PhysicalyTherapypyo Occupational Therapyo Speech Therapyo Medical Social Worko Respiratory Therapy50 It can also be not‐so‐high skilledlaborParaprofessional home health agency services include:o Home Health Aideso Personal Care Assistantso Physical Therapy Assistantso Certified Occupational Therapy Assistants (COTA)Custodial home care services include:o Homemaker and housekeepingo Companionso Private duty helpo Live-in serviceso Hourly or shift coverageMostly for agedpopulation and inrecovery/rehabphases from majorprocedures5117
Home Medical EquipmentHome Medical Equipment services include providing durablemedical equipment, such as:o Artificial limbso Prostheticso Bedso Braceso Caneso Crutcheso Wheelchairso Commodeso Respiratory equipment (concentrators)o Oxygen52 An Example: Hospice Care Hospice care at home is often preferred bypatients:– Psychologically better– Emotionally better– Spiritually better Palliative care, pain management, physicianservices, etc 53 4. Complementary & AlternativeMedical Care5418
What is complementary andalternative medical care? In 1992, Congress established the Office ofAlternative Medicine (OAM)– Determine effectiveness of alternative medicalcare National Center for Complementary andAlternative Medicine (NCCAM)– “ those treatments and healthcare practices nottaught widely in medical schools, not generallyused in hospitals, and not usually reimbursed bymedical insurance companies”55 Types of CAM practices with examples1. Alternative Medical systems – Ayurveda,homeopathy, naturopathy2. Mind‐Body Interventions – use of hypnosis, dance,music, art therapy, prayer and mental healing3. Biological‐Based Therapies – herbal, special dietary4. Manipulative and Body‐Based Methods –chiropractic, some osteopathic and massagetherapy5. Energy Therapies ‐ magnetic, bio‐electro‐magnetic, therapeutic touch etc.56 Utilization in the U.S. Estimated 629 million visits to CAM providersin 1997 South Carolina study:– 44% off adultsd lt hhadd usedd CAM– 60% perceived CAM as very effective Physicians were unaware of CAM use in 75%of their patients57(Source: Oldendick, Coker, Wieland, et al 2000; Southern Medical Journal, 93, 375-3810)19
AccreditationoDefine ambulatory careoDefine primary careoExplain subsets of ambulatory careoExplain ambulatory care and accreditationoChallenges and future of ambulatory care58Accreditation Ambulatory Care JCAHO established the Ambulatory HealthCare accreditation program in 1975 Ambulatory care facilities covered include– Ambulatory surgery centerscenters, Community health centerscenters, Groupmedical practices, Indian health clinics, Military clinics, Mobileservices, Multispecialty group practices, Occupational health centers,Office‐based surgery offices, Physician offices, Prison health centers,Student health services59 JCAHO A note on JCAHO and its surveyors– Not‐for‐profit– Highly experienced– Strong educational background An organization may be accredited as follows:––––––––Accreditation with Full Standards ComplianceAccreditation with Requirements for ImprovementProvisional AccreditationConditional AccreditationPreliminary Denial of AccreditationAccreditation DeniedAccreditation WatchAccreditation with Commendation6020
Accreditation vs. Licensure FrequencyNoticeFundingFocusFindingsAward Accreditation SurveysPerformanceimprovement; deemedstatus in some statesprivate, NFP der feesWhat is the organizationdoing right? How can itimprove?recommendations forimprovementaccreditationState Surveyslicensure and/orMedicare/Medicaidprovider certificationgovernmental entitymandatoryyinspectionannualunannouncedtax dollars or feesWhat is the organizationdoing wrong?citationslicensure or certification61Example list of ambulatory careorganizations that seek accreditation(Source: NCCAM) Birthing centers Cardiac catheterizationcenters Dental clinics Dialysis centers Endoscopy centers Imaging centers Infusion therapy services Laser centers Lithotripsy services MRI centers Ophthalmology practices Oral and maxillofacialsurgery centers Pain management centers Plastic surgery centers Podiatric clinics Radiation/oncology clinics Rehabilitation centers Sleep centers Urgent/emergency carecenters Women's health centers62 ChallengesoDefine ambulatory careoDefine primary careoExplain subsets of ambulatory careoExplain ambulatory care and accreditationoChallenges and future of ambulatory care6321
Current Issues in Ambulatory care1. Access to care : factors are Limited or no insurance coverageGeographical locationLanguage barrierCultural barrier etc.2. Cost Containment: factors are Increasing cost of drugsCost of new technologies3. Quality Improvement: factors are Under‐use of known treatments that can improve healthOver‐use of treatment with no positive impact on healthMisuse of treatmentEconomic condition64 The Challenges RestatedToday's health care environment is changing rapidly, andambulatory care providers are experiencing new competitivepressures in the health care marketplace.Providing high-quality care to patients and continually improvingperformance are benchmarks of success, but it is increasinglyimportant to demonstrate quality of care to payers, regulatoryagencies, and managed care organizations.A growing number of ambulatory care organizations seek JointCommission accreditation because they want to be representednationally as high-quality patient care providers.65 Data for the interestedUseful Website for Ambulatory Care .htm6622
organizations that seek accreditation (Source: NCCAM) Dialysis centers Endoscopy centers Imaging centers Infusion therapy services Laser centers Lithotripsy services MRI centers Plastic surgery centers Podiatric clinics Radiation/oncology clinics Rehabilitation centers Sleep centers Urgent/emergency care centers
Ambulatory Care Statistics Branch at 301-458-4600, or by e-mail at NCHSquery@cdc.gov. characteristics of patients making those visits, and the contents of the care provided is integral to monitoring the health of the 30 U.S. population and planning for future health care delivery needs. The National Ambulatory Medical Care Survey
Ambulatory Infusion Pump Kit REF Description 350-1000 1 - Curlin 4000 Plus Ambulatory Infusion Pump 2 - “C” size alkaline batteries 1 - AC power adapter/charger 1 - Hard carrying case 1 - User’s Manual 4000 Plus Ambulatory Infusion System EASY TO USE EASYTO SETUP SOP
Jan 01, 2021 · Code Ambulatory Surgical Center Services Fee Schedule 2021 The Ambulatory Surgical Center fee schedule does not have rates listed due to reimbursement though . 11750 11755 11760 11762 11765 Ambulatory Surgical Center Fee Schedule 2021 Page 3. Code
Perspectives in Ambulatory Care T HERE HAS NEVER BEEN a bet-ter time to be a nurse. Es - pecially for those nurses fortunate enough to prac-tice in ambulatory care settings. The Patient Protection and Affor - dable Care Act of 2010 focuses on prevention and wellness as well as improving quality and health system performance. One of the
nationally representative data on ambulatory care visits to hospital emergency departments (EDs) in the United States. Estimates are presented on selected hospital, patient, and visit characteristics using data collected in the 2017 National Hospital Ambulatory Medical Care Survey (NHAMCS).
outcomes. As such, processes that improve service integration are fundamental to an enhanced cancer system. the Princess Margaret Ambulatory Strategic Plan recognizes that the current cancer journey must be transformed and guided by the vision of providing an "Exemplary Patient-Centred Ambulatory Care Experience". 1.0 Executive Summary
visit characteristics using data collected in the 2015 National Hospital Ambulatory Medical Care Survey (NHAMCS). NHAMCS is an annual nationally representative sample survey of visits to EDs; outpatient departments; and hospital-based ambulatory surgical centers (ASCs) (sta
2.4 Overall structure of primary care 61 2.5 Good practices and challenges for structuring primary care 63 2.6 Conclusion 65 References Chapter 3 The delivery of primary care services 67 Andrew Wilson, Adam Windak, Marek Oleszczyk, Stefan Wilm, Toralf Hasvold, Dionne Kringos 3.1 Access to primary care 67 3.2 Continuity of primary care 77
