Plan For a Proposed Healthcare Facility

Week 1

An ambulatory healthcare facility is a healthcare facility that provides outpatient services, which are preventive, diagnostic, and treatment services that do not require an overnight stay. The rationale behind recommending this type of facility is that it can provide timely, cost-effective, and coordinated care, focusing on preventive services and managing chronic conditions. This type of facility would be recommended over a different kind if the patient does not need hospitalization or intensive care and can benefit from the convenience and accessibility of ambulatory care.

The type of health care delivery and services provided at an ambulatory care facility depends on the speciality and scope of the facility. Some examples of services that mobile care facilities provide are blood tests, biopsies, x-ray imaging, CT scans, ultrasounds, colonoscopies, mammograms, minor surgical procedures, radiation treatments, chemotherapy, primary care, mental health care, family planning, asthma education, chiropractic care, acupuncture, massage therapy, physical therapy, occupational therapy, and substance abuse counselling.

The type of staff that will work in an ambulatory care facility also varies depending on the type and size of the facility. However, some common positions and categories that can be found in most ambulatory care facilities are:

• • Physicians: They are licensed medical doctors who diagnose and treat patients. They may have different specialities, such as family medicine, internal medicine, paediatrics, obstetrics and gynaecology, surgery, oncology, radiology, etc. They may also have additional certifications or credentials, such as board certification or fellowship training.
  • Nurse practitioners are registered nurses with advanced education and training in a specific area of health care. They can provide primary and speciality care to patients under the supervision or collaboration of a physician. They can prescribe medications and order tests in most states. They may also have additional certifications or credentials such as adult-gerontology primary care nurse practitioner (AGPCNP-BC), acute care nurse practitioner (ACNP-BC), family nurse practitioner (FNP-BC), psychiatric-mental health nurse practitioner (PMHNP-BC), etc.
  • Physician assistants: They are licensed health professionals who practice medicine under the supervision of a physician. In most states, they can perform physical examinations, diagnose and treat illnesses, prescribe medications, order and interpret tests, and assist in surgery. They may also have additional certifications or credentials such as certified physician assistant (PA-C), certified surgical physician assistant (CSPA), etc.
  • Registered nurses are licensed health professionals who provide direct patient care and coordinate with other healthcare team members. They can administer medications, perform procedures, monitor vital signs, educate patients, document care, and supervise other nursing staff. They may also have additional certifications or credentials such as certified ambulatory perianesthesia nurse (CAPA), certified medical-surgical registered nurse (CMSRN), certified pediatric nurse (CPN), etc.
  • Licensed practical nurses: They are licensed health professionals who provide basic patient care under the direction of a registered nurse or a physician. They can perform tasks such as taking vital signs, giving injections, dressing wounds, collecting samples, and assisting with personal hygiene. They may also have additional certifications or credentials such as IV therapy certification (IVT), wound care certification (WCC), etc.
  • Medical assistants are unlicensed health workers who perform administrative and clinical tasks in an ambulatory care facility. They can perform tasks such as scheduling appointments, answering phones, filing records, taking medical histories, measuring vital signs, preparing patients for examinations or procedures, assisting physicians or nurses with tasks, and collecting specimens.

Week 2

The best reimbursement methods for an ambulatory care facility include fee-for-service, capitation, and a combination of fee-for-service and value-based reimbursement.

Each method has its pros and cons.

• • Fee-for-Service (FFS): This is a traditional reimbursement model where healthcare providers are paid for each service or procedure they perform.
    • Pros
      • Directly ties reimbursement to services provided, incentivizing high patient volume.
      • Provides a clear revenue stream for each service rendered.
      • Allows for greater flexibility in accommodating a diverse range of patient needs
    • Cons
      • This may incentivize overutilization of services, leading to increased healthcare costs.
      • It relies on a high volume of patients to generate revenue, which can be challenging for small or specialized facilities.
      • It does not directly incentivize quality outcomes or coordination of care
  • Capitation: In this model, healthcare providers are paid a fixed amount per patient enrolled, regardless of the services utilized
    • Pros
      • Preventive care, chronic disease management, and care coordination are encouraged to maintain patient health and reduce costs.
      • Provides a predictable and stable revenue stream, as payments are not dependent on the volume of services provided.
      • Incentivizes efficiency and cost-effective care delivery
    • Cons
      • Risk of under-compensation if the fixed payment is insufficient to cover the actual healthcare needs of the patients.
      • This may lead to reduced access to specialized or expensive services if the fixed payment is inadequate.
      • This can create challenges in managing financial risks, particularly for facilities with a high-risk patient population.
  • Combination of Fee-for-Service and Value-Based Reimbursement: This hybrid approach combines elements of FFS with incentives based on achieving certain quality and outcome metrics.
    • Pros
      • Encourages a focus on quality, patient outcomes, and value-based care.
      • Aligns reimbursement with the provision of high-quality and cost-effective care.
      • Allows for a balance between the revenue generated through FFS and the incentives provided by value-based reimbursement
    • Cons
      • Requires robust data collection and reporting systems to track quality metrics accurately.
      • Implementation and administration of value-based programs can be complex and resource-intensive.
      • This can create financial uncertainty during the transition period from FFS to value-based reimbursement.

The choice of reimbursement method(s) will have a significant impact on the financial operations of the ambulatory care facility. Each method has different implications for revenue generation, cost management, and the facility’s overall financial health.

• • Fee-for-Service: FFS can generate higher revenue for each service rendered, but higher expenses may be associated with providing a larger volume of services. Careful management of costs, optimizing operational efficiency, and effective billing and coding practices are crucial to maintaining profitability.
  • Capitation: Capitation provides predictable revenue but requires effective population health management and coordination of care to control costs. Successful implementation involves efficient resource utilization, preventive care programs, and strong relationships with payers and referral networks.
  • Combination of Fee-for-Service and Value-Based Reimbursement: This approach allows the facility to balance revenue generation through FFS with the incentives and rewards of value-based care. It encourages the delivery of high-quality care while managing costs effectively. However, it requires investment in data analytics, performance measurement systems, and care coordination capabilities.

Week 3

1. Electronic health records (EHRs) can provide several benefits for clinical decision-making and problem-solving, such as:
   • EHRs can provide accurate, up-to-date, and complete information about patients at the point of care, enabling quick access to patient records for more coordinated and efficient care.
   • EHRs can help providers more effectively diagnose patients, reduce medical errors, and provide safer care by providing clinical decision support (CDS) tools, such as alerts, reminders, guidelines, order sets, and calculators.
   • EHRs can improve patient and provider interaction and communication by facilitating information sharing and collaboration among healthcare providers and settings.
   • EHRs can enhance patient satisfaction and trust by providing access to their health information and enabling them to make care decisions.
   • EHRs can foster accountability and transparency by measuring and reporting the performance and outcomes of healthcare providers based on standardized indicators.
   • EHRs can stimulate innovation and learning by creating a competitive environment and providing feedback and support to healthcare providers.

The cost of implementing and managing an EHR depends on various factors, such as the type, size, and location of the healthcare facility, the features and functionalities of the EHR system, the vendor and service provider, the training and support needs, and the maintenance and upgrade requirements. However, some estimates from the web search results are:

• • Purchasing and installing an EHR system costs $15,000 to $70,000 per provider.
  • The cost of running an EHR system ranges from $4,000 to $8,000 monthly for a practice of five physicians.
  • Training staff to use an EHR system averages $1,500 per provider.
  • The cost of maintaining and upgrading an EHR system varies depending on the vendor contract and service level agreement.

The security concerns surrounding health information technology (HIT) and EHRs are related to protecting electronic protected health information (e-PHI) from unauthorized access, use, disclosure, modification, or destruction. Some examples of security concerns from the web search results are:

• • Inappropriate releases of e-PHI from individual organizations due to human errors, negligence, or malicious actions by insiders or outsiders.
  • Systemic flows of e-PHI throughout the health care and related industries due to a lack of standards, policies, or agreements for data exchange or interoperability.
  • Cyberattacks or breaches target e-PHI for financial gain, identity theft, fraud, or sabotage by hackers or criminals using various methods such as phishing, malware, ransomware, denial-of-service attacks, or social engineering.
  • Loss or theft of e-PHI due to natural disasters, environmental hazards, or unauthorized intrusion that affect the physical security of electronic devices or systems that store or transmit e-PHI.

The Health Insurance Portability and Accountability Act (HIPAA) is a federal legislation that imposes requirements for using HIT and EHRs. Some of these requirements are:

• • The HIPAA Privacy Rule establishes national standards for protecting certain health information held or transferred by covered entities (health plans, health care clearinghouses, and health care providers) and their business associates. The Privacy Rule gives patients rights over their health information and limits who can access or disclose it.
  • The HIPAA Security Rule establishes national standards for the security of electronically protected health information (e-PHI) created, received, maintained, or transmitted by covered entities and their business associates. The Security Rule requires covered entities and their business associates to implement administrative, physical, and technical safeguards to ensure the confidentiality, integrity, and availability of e-PHI.
  • The HIPAA Breach Notification Rule requires covered entities and their business associates to notify affected individuals, the Secretary of HHS, and sometimes, the media when a breach of unsecured protected health information occurs. A violation is an impermissible use or disclosure of protected health information that compromises security or privacy.

Week 4

In the United States, a common accrediting body for ambulatory care facilities is The Joint Commission (TJC). TJC is an independent, nonprofit organization that accredits and certifies healthcare organizations and programs based on their compliance with rigorous quality and safety standards. Accreditation is voluntary but highly valued by healthcare organizations as it demonstrates their commitment to providing high-quality care. The accreditation process involves a comprehensive evaluation of the facility’s compliance with TJC’s standards, including patient care, medication management, infection control, governance, and patient safety. Successful Accreditation signifies that the facility has met or exceeded these standards.

Healthcare organizations have ethical and legal responsibilities to ensure their facilities are properly licensed, certified, and accredited. These requirements protect patients and uphold the quality and safety of healthcare services. Key considerations include:

• • Licensure: Licensure is a legal requirement that healthcare facilities must fulfil to operate legally. The specific requirements for licensure vary by state in the United States. Healthcare organizations must comply with state regulations, submit applications, and meet particular infrastructure, staffing, quality, and patient safety criteria.
  • Certification: Certification is often required for certain specialities or services within a healthcare facility. For example, the Centers for Medicare and Medicaid Services (CMS) involves certification for participation in federal healthcare programs such as Medicare. Certification ensures that the facility meets specific standards and can provide designated services.
  • Accreditation: Accreditation is a voluntary process that goes beyond licensure and certification. It involves meeting rigorous standards set by accrediting bodies like The Joint Commission. Ethically, healthcare organizations are responsible for pursuing Accreditation to ensure high-quality care and patient safety. Accreditation enhances the organization’s reputation, instils patient confidence, and may be required for insurance reimbursement.

For an ambulatory care facility in California, the licensure requirements may include:

• • Application and Fees: Submitting a completed application along with the required fees.
  • Ownership and Governance: Providing information about the facility’s ownership structure, governance, and responsible individuals.
  • Physical Environment: Complying with regulations related to the facility’s physical environment, such as safety standards, accessibility, and infection control.
  • Staffing: Meeting requirements for staffing, including appropriate ratios of licensed professionals and support staff.
  • Quality Assurance: Demonstrating processes and protocols for quality assurance, patient safety, and risk management.

Week 5

Patient satisfaction and clinical outcome measures are two types of measures that are currently used to gauge quality in health care. Patient satisfaction measures assess the patient’s perception of the quality and experience of care received at a healthcare facility, such as access, communication, coordination, and customer service. Clinical outcome measures assess the health status or results of care for patients, such as mortality, morbidity, complications, or readmissions.

The data for these measures can be collected and analyzed by using the following methods:

• • For patient satisfaction, the data can be collected by administering the CAHPS survey to a representative sample of patients who visited the ambulatory care facility within a specified time frame. The survey can be helped by mail, phone, web, or mixed modes. The data can be analyzed using the CAHPS analysis program or other statistical software to calculate and compare the scores with benchmarks or other facilities.
  • For clinical outcomes, the data can be collected using electronic health records (EHRs), claims data, registries, or clinical databases containing information on patient characteristics, diagnoses, treatments, and outcomes. The data can be analyzed using various methods such as risk adjustment, case-mix adjustment, statistical process control charts, or benchmarking to account for differences in patient populations and compare performance across providers or facilities.

Some realistic benchmarks for these measures are:

• • For patient satisfaction, a possible benchmark is the national average score for each CAHPS survey composite or item based on the most recent data available from the Agency for Healthcare Research and Quality (AHRQ). For example, according to the 2019 CAHPS database, the national average score for “How well providers communicate” was 92.6 out of 100. The rationale for using this benchmark is that it reflects the performance of similar ambulatory care facilities across the country and can be used to identify areas for improvement or excellence.
  • For clinical outcomes, a possible benchmark is the national or regional average rate for each outcome measure based on the most recent data available from reliable sources such as the Centers for Medicare & Medicaid Services (CMS), the Joint Commission, or other quality organizations. For example, according to the CMS Hospital Compare website, the national average rate for hospital readmissions within 30 days after discharge for heart failure patients was 21.9% in 2019. The rationale for using this benchmark is that it reflects the expected level of performance based on evidence-based standards and best practices.