만성질환자 관리 : 재활 세브란스병원 간호부장 김 현 옥

 Political Trends  Economic Trends  Demographic Trends  Technological Trends  Societal Trends  Professional Organization Trends Trends Affecting Health Care

  Health Care Cost   Health Care Demands  Role of Customers  Available Health Information  Specialization 의료환경 변화

Components of Healthcare System  Healthcare payers  Healthcare providers  Healthcare receivers

Healthcare Payers( 보험 )  Government Cost based Prospective (DRGs)  Private : Managed Care - Prospective payment

Managed Care  Payers demand quality services  Clinical/Critical Pathways  Outcomes Management  Service Coordination   Health care competition

Health Care Providers( 병원 )   Length of stay  Management of service utilization  Standardization : Critical/clinical pathways  Outcomes management Ways to manage cost

Effects of LOS  Development of healthcare continuum :  Acute care services  Post acute care services  Acute rehabilitation  Sub-acute care  Home care  Outpatients  Long term care

Healthcare Continuum Peak wellness No symptoms Symptoms Disease/Injury Disability Screening Early detection Diagnosis Rehabilitation Health Death Preventioin Maintenance Focus Acute care hospitals Acute Rehab.Hosp. Sub-acute care center Home care Outpatient clinics Outpatient Clinics Level of Services Supportive care Long term care center

Disease Management  Community based system  Integrated service network  Clinical standards  Physician direction Key concepts

Acute Hospital Subacute Long Team care Home care Rehabilitation Subacute Outpatient Home care LTC Home care Primary physician Disease Management: Collaboration Model Medical Management Rehab. effort Health Maintenance End stage

Disease Management: Scope of Services Physical DimensionPsychosocial Dimension Social Dimensian Acute careMedical care Rehabilitation Acute/Subacute Medical care ADL functions (Maximize) Adoptation Anxiety Depression Family dynamics Home careMedical care ADL functions (Maximize) Adoptation Depression Anxiety Family dynamics Occupation Recreation Religion Out patientADL functions (maximize) Occupation Long term careMedical care ADL(Maintenance) Quality of life

재활환자 경향  Rehabilitation = Physical Medical Rehabilitation(PMR)  Physical Rehabilitation Medical Rehabilitation

Rehabilitation Diagnoses Old Old  Stroke  BI  SCI  Neurology  Arthritis (Osteo)  Arthritis (Rheumatoid)  Amputation  Multi Fracture  Burns New New  Cardiac  Pulmonary  Pain  Fx of LE  Ortho Replacement  Medically complex  Debility

Rehabilitation Nursing : Definition  Assist individuals affected by chronic illness or physical disability

Goals of Rehabilitation  To achieve individual ’ s greatest potential  To adapt to their disabilities  To work toward productive, independent lives

Rehabilitation approach  A Holistic approach to meeting patient needs :  Medical  Educational  Vocational  Environmental  Spiritual  Emotional

Rehabilitation practice  Managing complex medical issues  Collaborating with other specialists  Providing patient/family education  Setting goals for optimal independence  Establishing plans of care to maintain optimal wellness

Rehabilitation Nurses Roles  Rehabilitation nurse  Rehabilitation education  Rehabilitation clinical specialist  Case manager  Admission liaison (evaluator)  Rehabilitation manager  Administrator  Insurance nurse  Legal nurse

Prospective Payment System for Inpatient Rehabilitation Facilities  1997 balanced Budget Refinement Act(BBRA)  A per discharge prospective payment system

Goals  To control healthcare cost increase  To redistribute the total amount of payments to rehabilitation facilities  To make payment by rehabilitation patient characteristics  To promote access to rehabilitation facilities

Major Elements of the IRF PPS  Patient Assessment Instrument  Patient Classification System  CMG Relative Weights  Payment Rates

Payment Assessment Patient Classification CMGs Payment

Patient Classification System  Impairment  Functional capabilities  Motor  Cognition  Age  Comorbidities

Outcome of DPS   LOS

Rehabilitation Management Issues  Preadmission process  Discharge planning  Management of LOS  Cost management  Ancillary service utilization

Rehabilitation Outcomes ( )  Cost  200%  Onset days  30% (early admission to rehab)  FIM change  3%  LOS  20%  Community D/CSame

Changes in rehabilitation practice  Goal setting: Short term  Team approach  Service utilization  24hrs Nursing care  Therapy follow-up  Trans-disciplinary approach

Cost Management  Re-engineering-Integration  Vertical  Horizontal  Streamlining care process  Less money available  How we deliver  Cost to deliver care to different groups of patient  Where cost can be reduced  Maintain quality and financial viability

Cost Management  Care management Clinical pathways  Standardization  Service quality  Information technology  Human resources management  Nursing Shortage/ Flexibility  Cross-training