Managed Care : A Nursing Perspective / Edition 1

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Overview

Anita W. Finkelman, MSN, RN, University of Cincinnati College of Nursing

Focusing on the impact of managed care on the health care delivery system and its effect on nursing, this book provides advanced practitioners with a comprehensive understanding of how managed care works. It guides readers through the maze of managed care with solid coverage of a wide variety of topics related to health care organizations, reimbursement, quality care, legal and ethical issues, changes in roles and responsibilities, tools and strategies used to monitor care, and changes in clinical practice.

FEATURES

  • FREE Interactive Companion Website includes key terms with definitions, current events, internet exercises, study guide, message board, and faculty resources.
  • Internet Activities offer suggestions for further research on the World Wide Web and contain URLs for activities that correlate to each chapter.
  • Covers topics that expand upon managed care, such as the health care delivery system, legislation, nursing professional practice issues, and case management.
  • Four major themes of the book -- The Health Care Environment: What It Is and How It Is Affected by Managed Care; Managed Care: What It Is and How It Works; Issues Affecting the Results of Managed Care; Managed Care: Implementations for the Nurse -- are divided into separate units to help readers better understand managed care.
  • Questions and Activities for Thought present readers with material that addresses critical issues related to content in each chapter, and encourages them to relate and apply this information to their own communities.
  • Chapter objectives and summaries serve as a valuable guide for establishing and reviewing learning goals.

Author Biography:

ANITA FINKELMAN, MSN, RN, is founder and president of Resources for Excellence, a health care consulting firm. She is currently Adjunct Associate Professor/Clinical Nursing at the University of Cincinnati College of Nursing. She has served as Director of Continuing Education and Associate Professor/Clinical Nursing at the University of Cincinnati College of Nursing. Her 30 years of experience in psychiatric nursing includes clinical, educational, and administrative roles in a variety of health care settings. In her administrative positions, she has had experience with managed care and has developed and taught a course on managed care. Ms. Finkelman has authored many books and lectured frequently on administration, managed care, continuing education, and psychiatric nursing, both nationally and internationally, and has also been active in many professional organizations such as the American Psychiatric Nurses Association and Sigma Theta Tau. She also serves on the Editorial Advisory Committee and Editorial Board for Home Care Provider. Ms. Finkelman has published many books and journal articles throughout her career, including Psychiatric-Mental Health Case Studies published inCritical Thinking in Nursing: Case Studies Across the Curriculum, Carol Green (Ed.), Prentice Hall Health, 1999; Psychiatric Home Care, Aspen Publishers, Inc., 1997; Psychiatric Administration Manual, Aspen Publishers, Inc., 1994 (annual supplements 1995, 1996); Quality Assurance for Psychiatric Nursing, Aspen Publishers, Inc., 1990 (annual supplements: 1991, 1992, 1993, 1994). She has also contributed chapters on the topic of health care delivery and managed care for other new textbooks to be published in 2001, including "The Health Care Delivery System," in Community Health Nursing" Promoting the Health of Aggregates, Mary Nies and Melanie McEwen (Eds.), W.B. Saunders Company.

This book is a primer on how managed care works; its advantages and disadvantages, its relationship to the patient, and the inter-relationship of financial, quality, and ethical issues that arise in daily practice.

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Editorial Reviews

From The Critics
The impact of managed care on the health care delivery system and its effect on nursing is examined in this text for junior and senior undergraduates and graduate students. The text integrates coverage of issues related to health care management, the nursing process, and nursing practice, in chapters on reimbursement, managed care organization, case management and collaborative care, legal and ethical issues, managed care and the consumer, and the effects of managed care on the patient. Learning features include chapter summaries, questions and activities, and Internet exercises. Finkelman teaches clinical nursing at the University of Cincinnati. Annotation c. Book News, Inc., Portland, OR
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Product Details

  • ISBN-13: 9780805381528
  • Publisher: Pearson
  • Publication date: 10/10/2000
  • Edition number: 1
  • Pages: 528
  • Product dimensions: 7.99 (w) x 10.00 (h) x 0.30 (d)

Read an Excerpt

Preface

PREFACE

As the twentieth century ended, the health care environment had undergone rapid change. The primary stimuli for these changes have been increasing medical costs and managed care. Providers of care, patients and their families, third-party payers, and state and federal governments have all struggled to understand managed care, its implications, and its disadvantages, as well as appreciate its advantages. How is nursing coping with this changing health care environment and with managed care? Managed care is still very new to nursing in both its education and in practice. In order to provide cost-effective, quality care, one of the most important issues for nurses is to understand and make the best use of the managed care environment. To do this, nursing education programs that incorporate managed care content into their curricula at all levels will graduate the better prepared nurses. In 1995, the American Nurses Association recognized the importance of managed care content by developing and publishing a sample managed care curriculum for baccalaureate nursing programs. This effort clearly indicates a recognition that many nurses will practice in the managed care environment, whether they have direct roles in managed care organizations or practice in a clinical setting. Graduate programs also need to include this content because most nurses who are entering graduate school did not have this content in their undergraduate programs. When I included content about managed care in courses that I have taught, the students felt that this content was highly relevant to them and disturbed that it had not been included earlier in their education. Advanced practicenurses who are independent practitioners or work for health care organizations cannot function successfully without an understanding of how managed care works, its advantages and disadvantages, its relationship to the patient, and the interrelationship of financial, quality, legal issues, and ethics that arise daily as one practices.

To be successful, provide quality care, continue to be an advocate for the patient and the patient's family, and also be recognized as a critical member of the health care team, nurses must recognize the importance of managed care to nursing practice. Nursing has experienced threats to its functions and roles. Now, nursing must find a place for itself and define how it can contribute in the new managed care environment. As managed care will continue to change, nurses can play a role in defining the future of managed care. With managed care's unsettled issues, nurses can make a major contribution to the resolution of issues such as patient rights, quality of care, patient/consumer education, and much more. Nurses do hold positions in managed care organizations, such as case managers, direct care providers within health maintenance organizations, and administrative positions. However, there will be many more opportunities for nurses. Will nursing be ready for them? Will nursing even be able to identify these positions and be assertive in obtaining them? None of this will happen without education and understanding.

The content of this textbook focuses on the impact of managed care on the entire health care delivery system and its effect on nursing. Four major themes are used to guide the reader through the maze of the managed care environment:

  • The Health Care Environment
  • Managed Care: What Is it and How Does It Work?
  • Issues Affecting the Results of Managed Care
  • Managed Care: Implications for the Nurse

Recognizing the need for a wide variety of information related to health care organization, reimbursement, quality care, legal issues, ethics, changes in roles and responsibilities, tools and strategies used to monitor care, and changes in clinical practice, the content incorporates the most recent information that is available. Questions and activities for thought recommend more in-depth analysis of local community health care delivery systems and application of content to clinical settings and specific populations. The reader is encouraged to explore new information via the Internet and suggested activities. Critical thinking is required in considering difficult topics whose implications for the health care delivery system and nursing are still unknown.

The content is appropriate for junior and senior years undergraduate students, and graduate nursing students. The textbook is applicable to courses with content on managed care, health care policy and ethics, trends and issues, health care and nursing history, administration and management, and health care financing. Application of the material should be presented in all clinical courses. For example, students who are assigned to a labor and delivery unit need to understand the implications of managed care on the mother-infant discharge date. What has happened with this issue? How has legislation tried to resolve the issue? Is this the best approach? What effect does the managed care organization or insurer and the patient's benefits have on clinical care? How does managed care affect the nurse's documentation? What patient education issues are relevant?

The text provides content about managed care and addresses issues related to health care management, the nursing process, and nursing practice, thereby preparing the reader to understand their interrelationships. Clinical practice takes place in organizations, not in isolation. Nurses must be prepared to practice in these organizations and to contribute to the development of a more cost-effective health care delivery system that provides quality care. This textbook will assist in preparing nurses for practice in the new century.

ADDITIONAL STUDENT AND FACULTY RESOURCES

Due to the nature of managed care and the changes in the health care system, the content in this book can become outdated quickly. Each chapter includes Internet Activities, with suggestions for further research on the World Wide Web. Additionally, the textbook has an on-line companion Web site that provides updates for content, as well as a variety of student and faculty resources. By accessing the Web site students can enrich their learning with the following online activities for each chapter:

  • Key Terms—Glossary and review of definitions
  • Current Events—Links current events with questions related to managed care and the health care system on the World Wide Web.
  • Internet Exercises—Short answer questions in response to student's search on the Web
  • Study Guide—Interactive workbook with True or False, Test Yourself, and Critical Thinking exercises
  • Message Board—Questions posted for class discussion

In all cases, students can get instant feedback or e-mail results to the instructor with the click of a button. Under the menu of Faculty Resources, instructors can access lecture outlines, annotated links, and update on references for all chapters. Prentice Hall is pleased to provide a free online Syllabus Manager that assists students and faculty with incorporating the Internet resources and activities into your course. Finally, other online course options are available to adopters of this textbook. For more information, please contact your local Prentice Hall Health Sales Representative.

ACKNOWLEDGMENTS

A project of this size requires the assistance and support of many people, and I have been lucky to have this from colleagues and family. I thank Carole Kenner, DNS, RNC, FAAN; Edith Neusner, BSN, RNC; and Lisa Dreyer, MSN, RNC, for their assistance during this project and their support through stressful periods, and Andrea R. Linden, DNSc, RN, Dean at the University of Cincinnati College of Nursing, for encouraging me to develop a course on managed care. A special thanks to Lynn Cox, who originally agreed to pursue this project with me; Maura Connor, Executive Editor for Nursing at Prentice Hall Health, and her staff, who provided editorial support to the end; Linda Begley and staff at Rainbow Graphics; and all of the reviewers.

Read More Show Less

Table of Contents

Preface XVII
About the Author XIX
Acknowledgments XX
Part I The Health care Environment 1
Chapter 1 The Changing Health Care Environment 2
Chapter 2 Reimbursement: a Driving Force 15
Part II Managed Care: What Is It and How Does It Work? 49
Chapter 3 Managed Care Organization: the Managed Care Maze 50
Chapter 4 Managed Care Strategies: Performance and Cost 79
Chapter 5 Case Management and Collaborative Care 123
Chapter 6 Clinical Pathways and Other Tools for Managing Care 150
Part III Issues Affecting the Results of Managed Care 179
Chapter 7 Legal and Ethical Issues 180
Chapter 8 Quality Care in the Managed Care Environment 220
Chapter 9 Managed Care and the Consumer 256
Chapter 10 Medicare and Medicaid: a Managed Care Approach 290
Part V Managed Care: Implications for the Nurse 339
Chapter 11 The Nurse and Managed Care 340
Chapter 12 Managed Care and its Effect on Patient Care 385
Chapter 13 Advanced Practice Nurse and Managed Care 416
Chapter 14 Future: Are we Up to the Challenge? 447
Appendices 453
Glossary 479
Index 493
Read More Show Less

Preface

PREFACE

As the twentieth century ended, the health care environment had undergone rapid change. The primary stimuli for these changes have been increasing medical costs and managed care. Providers of care, patients and their families, third-party payers, and state and federal governments have all struggled to understand managed care, its implications, and its disadvantages, as well as appreciate its advantages. How is nursing coping with this changing health care environment and with managed care? Managed care is still very new to nursing in both its education and in practice. In order to provide cost-effective, quality care, one of the most important issues for nurses is to understand and make the best use of the managed care environment. To do this, nursing education programs that incorporate managed care content into their curricula at all levels will graduate the better prepared nurses. In 1995, the American Nurses Association recognized the importance of managed care content by developing and publishing a sample managed care curriculum for baccalaureate nursing programs. This effort clearly indicates a recognition that many nurses will practice in the managed care environment, whether they have direct roles in managed care organizations or practice in a clinical setting. Graduate programs also need to include this content because most nurses who are entering graduate school did not have this content in their undergraduate programs. When I included content about managed care in courses that I have taught, the students felt that this content was highly relevant to them and disturbed that it had not been included earlier in their education. Advanced practicenurses who are independent practitioners or work for health care organizations cannot function successfully without an understanding of how managed care works, its advantages and disadvantages, its relationship to the patient, and the interrelationship of financial, quality, legal issues, and ethics that arise daily as one practices.

To be successful, provide quality care, continue to be an advocate for the patient and the patient's family, and also be recognized as a critical member of the health care team, nurses must recognize the importance of managed care to nursing practice. Nursing has experienced threats to its functions and roles. Now, nursing must find a place for itself and define how it can contribute in the new managed care environment. As managed care will continue to change, nurses can play a role in defining the future of managed care. With managed care's unsettled issues, nurses can make a major contribution to the resolution of issues such as patient rights, quality of care, patient/consumer education, and much more. Nurses do hold positions in managed care organizations, such as case managers, direct care providers within health maintenance organizations, and administrative positions. However, there will be many more opportunities for nurses. Will nursing be ready for them? Will nursing even be able to identify these positions and be assertive in obtaining them? None of this will happen without education and understanding.

The content of this textbook focuses on the impact of managed care on the entire health care delivery system and its effect on nursing. Four major themes are used to guide the reader through the maze of the managed care environment:

  • The Health Care Environment
  • Managed Care: What Is it and How Does It Work?
  • Issues Affecting the Results of Managed Care
  • Managed Care: Implications for the Nurse

Recognizing the need for a wide variety of information related to health care organization, reimbursement, quality care, legal issues, ethics, changes in roles and responsibilities, tools and strategies used to monitor care, and changes in clinical practice, the content incorporates the most recent information that is available. Questions and activities for thought recommend more in-depth analysis of local community health care delivery systems and application of content to clinical settings and specific populations. The reader is encouraged to explore new information via the Internet and suggested activities. Critical thinking is required in considering difficult topics whose implications for the health care delivery system and nursing are still unknown.

The content is appropriate for junior and senior years undergraduate students, and graduate nursing students. The textbook is applicable to courses with content on managed care, health care policy and ethics, trends and issues, health care and nursing history, administration and management, and health care financing. Application of the material should be presented in all clinical courses. For example, students who are assigned to a labor and delivery unit need to understand the implications of managed care on the mother-infant discharge date. What has happened with this issue? How has legislation tried to resolve the issue? Is this the best approach? What effect does the managed care organization or insurer and the patient's benefits have on clinical care? How does managed care affect the nurse's documentation? What patient education issues are relevant?

The text provides content about managed care and addresses issues related to health care management, the nursing process, and nursing practice, thereby preparing the reader to understand their interrelationships. Clinical practice takes place in organizations, not in isolation. Nurses must be prepared to practice in these organizations and to contribute to the development of a more cost-effective health care delivery system that provides quality care. This textbook will assist in preparing nurses for practice in the new century.

ADDITIONAL STUDENT AND FACULTY RESOURCES

Due to the nature of managed care and the changes in the health care system, the content in this book can become outdated quickly. Each chapter includes Internet Activities, with suggestions for further research on the World Wide Web. Additionally, the textbook has an on-line companion Web site that provides updates for content, as well as a variety of student and faculty resources. By accessing the Web site at http://www.prenhall.com/finkelman, students can enrich their learning with the following online activities for each chapter:

  • Key Terms—Glossary and review of definitions
  • Current Events—Links current events with questions related to managed care and the health care system on the World Wide Web.
  • Internet Exercises—Short answer questions in response to student's search on the Web
  • Study Guide—Interactive workbook with True or False, Test Yourself, and Critical Thinking exercises
  • Message Board—Questions posted for class discussion

In all cases, students can get instant feedback or e-mail results to the instructor with the click of a button. Under the menu of Faculty Resources, instructors can access lecture outlines, annotated links, and update on references for all chapters. Prentice Hall is pleased to provide a free online Syllabus Manager that assists students and faculty with incorporating the Internet resources and activities into your course. Finally, other online course options are available to adopters of this textbook. For more information, please go to http://www.prenhall.com/health or contact your local Prentice Hall Health Sales Representative.

ACKNOWLEDGMENTS

A project of this size requires the assistance and support of many people, and I have been lucky to have this from colleagues and family. I thank Carole Kenner, DNS, RNC, FAAN; Edith Neusner, BSN, RNC; and Lisa Dreyer, MSN, RNC, for their assistance during this project and their support through stressful periods, and Andrea R. Linden, DNSc, RN, Dean at the University of Cincinnati College of Nursing, for encouraging me to develop a course on managed care. A special thanks to Lynn Cox, who originally agreed to pursue this project with me; Maura Connor, Executive Editor for Nursing at Prentice Hall Health, and her staff, who provided editorial support to the end; Linda Begley and staff at Rainbow Graphics; and all of the reviewers.

Read More Show Less

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