Introduction
With technological innovation, health care delivery has increasingly shifted away from expensive stays in acute care hospitals. As a result, a variety of outpatient settings and services have become common. Outpatient care, also commonly refe
ed to as Ambulatory Care includes all health services that do not require an overnight stay in a health care facility. The scope of practice ranges from general medicine (primary care) and subspecialty care (e.g. Urology, Cardiology, etc.) to more procedure-oriented health care services such as ambulatory surgeries.
Learning Objectives:
1. Describe the roles outpatient services and primary care play in today’s health care delivery.
2. Know the different outpatient care settings as well the different methods of service delivery.
3. Define Primary Care and understand the importance of this level of care for any given population
4. Identify and explain the different domains of Primary Care
5. Name each and give examples of reasons that prove the effectiveness of primary care
Glossary of Terms:
1. Ambulatory care: Ambulatory care includes (1) care rendered to patients who come to physicians’ offices, outpatient departments of hospitals, and health centers to receive care; (2) outpatient services intended to serve the su
ounding community (community medicine); and (3) certain services that are transported to the patient. Also refe
ed to as outpatient services.
2. Community-oriented primary care: Incorporates the elements of good primary care delivery and adds a population-based approach to identifying and addressing community health problems.
3. Complementary and alternative medicine: Refers to the
oad domain of all health care resources, other than those intrinsic to biomedicine.
4. Freestanding Facility: A site that offers health care services that are not physically part of an Integrated Delivery System’s (IDS) defined campus location or building. Freestanding facilities can however still be a part of any IDS. Freestanding facilities that are independent and not part of any IDS are often refe
ed to as Stand-alone facilities.
5. Gatekeeping: The use of primary care physicians to coordinate health care services needed by an enrollee in a managed care plan.
6. Hospice: A cluster of special services for the dying, which blends medical, spiritual, legal, financial, and family-support services. The venue can vary from a specialized facility to a nursing home to the patient’s own home.
7. Medical home: Patient-centered care based on the principles of the chronic care model. Uses evidence-based guidelines; applies appropriate health information technology; and demonstrates the use of “best practices” to consistently and reliably meet the needs of patients while being accountable for the quality and value of care provided.
8. Outpatient services: As opposed to inpatient services, outpatient services include any health care services that are not provided based on an overnight stay in which room and board costs are incu
ed. See ambulatory care.
9. Palliative: Serving to relieve or alleviate, such as pharmacological pain management and nausea relief.
10. Secondary care: Routine hospitalization, routine surgery, and specialized outpatient care, such as consultation with specialists and rehabilitation. Compared to primary care, these services are usually
ief and more complex, involving advanced diagnostic and therapeutic procedures.
11. Surgicenter: A freestanding, ambulatory surgery center that performs various types of surgical procedures on an outpatient basis.
12. Tertiary care: The most complex level of care. Typically, tertiary care is institution based, highly specialized, and highly techno- logical. Examples include burn treatment, transplantation, and coronary artery bypass surgery.
13. Urgent care center: A walk-in clinic that is generally open to see patients after normal business hours in the evenings and week- ends without having to make an appointment.
14. Walk-in clinic: A freestanding, ambulatory clinic in which patients are seen without appointments on a first come, first served basis.
Lesson 1: Out patient care
Outpatient Care services. Outpatient care refers to any health care services that do not require an overnight stay in an institution of health care delivery, such as a hospital or long-term care facility. It includes much more than primary care services.
Reimbursement, technological factors, utilization control factors, and social factors are key changes that have been instrumental in shifting the balance between inpatient and outpatient services. In regard to reimbursement, both private and public payers have a clear preference for outpatient treatment because it costs less than inpatient care. Technological factors include the development of new diagnostic and treatment procedures and less invasive surgical methods that have made it possible to provide services in outpatient set- tings that previously had required inpatient stays in hospitals.
One of the social factors creating this shift is that patients generally have a strong preference for receiving health care in home and community-based setting.
Ambulatory Care sevices. The term ambulatory care is used interchangeably with outpatient services. Primary care is delivered on an outpatient basis and is therefore ambulatory. However, the scope of ambulatory services extends beyond primary care.
For example, hospital emergency departments and trauma centers provide secondary and tertiary care. Outpatient surgery and rehabilitative therapies are examples of ambulatory services that are not primary care. Certain tertiary treatments, such as renal dialysis and chemotherapy, are also commonly rendered in outpatient settings.
Solo practices and Group practices. Solo practices are becoming more and more rare in the United States. Very few graduates of residency programs are entering solo practice. Several factors account for this shift: rapid changes in the health delivery system, contracting by MCOs with consolidated rather than solo entities, competition from larger health delivery organizations, the high cost of establishing a new practice, the complexity of billing and collections in a multipayer system, and increased external controls over private medical practice.
Group practice and other organizational a
angements offer the benefits of having a patient refe
al network; negotiating leverage with MCOs; sharing of overhead expenses; ease of obtaining coverage from colleagues for personal time off; and, in a growing number of instances, attractive starting salaries along with benefits and profit-sharing plans.
Most young physicians find that these advantages far outweigh the allure of being an independent practitioner.
Misuse of Emergency Departments for outpatient Care. Reasons for emergency department use for nonurgent care include e
oneous self-perceptions of the severity of ailment or injury, the 24-hour open-door policy, convenience, and unavailability of primary care providers.
Because many private physicians do not provide services to Medicaid enrollees because of low reimbursement rates, Medicaid beneficiaries often have no primary care provider. Since emergency departments are required by law to evaluate every patient regardless of ability to pay, Medicaid patients and the uninsured frequently use them for primary care treatments. Even the insured sometimes feel that they need medical attention immediately regardless of how their problem might be classified by a provider.
Such patients present themselves at the emergency department because they cannot find needed care elsewhere. Because the emergency department requires sophisticated facilities and highly trained personnel and must be accessible 24 hours a day, costs are high, and services are not designed for nonurgent care. Inappropriate use of the emergency department wastes precious resources.
Outpatient care: a strategic key component in overall business strategy for Integrated Delivery Systems (IDS): Outpatient services now constitute a key source of profits for hospitals. As hospitals have seen inpatient revenues steadily erode, they have expanded outpatient services.
Under prospective and capitated reimbursement methods, more and more patients are now being discharged from inpatient beds earlier than before, and these patients represent a substantial market for ongoing outpatient services. Outpatient services are generally reimbursed on a fee-for- service basis independent of prospective reimbursement for inpatient care. A hospital providing both inpatient and outpatient services can enhance its revenues by refe
ing postsurgical cases to its affiliated units for rehabilitation and home care follow-up.
Patients receiving various types of out- patient services constitute an important source of refe
als back to the hospital for inpatient care. A hospital can thus expand its patient base. Industry experts believe hospitals will continue to derive a greater share of their total revenues from ambulatory services.
Due to declining inpatient occupancy rates, hospital executives have been forced to view ambulatory care as an essential portion of their overall health care business rather than a supplemental product line of an inpatient facility. Seeing their inpatient business erode, hospital administrators have realized that establishing a firm position in the ambulatory care market is critical to the continued survival of their organizations.
To meet the growing demand for outpatient services, hospitals have expanded into services that previously were not considered a part of their core business. The growth of non-hospital-based ambulatory services has intensified competition for outpatient medical services between hospitals and community-based providers. Examples of such competition include home health care and ambulatory clinics for routine and urgent care.
Lesson2: Outpatient care
This lesson discusses outpatient care’s different settings and methods of delivery. Outpatient care setting refers to the physical site where outpatient health care services are provided, for example a doctor’s clinic, the health department, or a community health center. In terms of method of delivery, this refers to the type of outpatient healthcare service being given, for example a nursing visit provided by a visiting nurse at the home of the patient. Full hospice care (for the terminally-ill) being provided at home is also an example of method of delivery for an outpatient healthcare service.
The 5 main hospital-based outpatients services. Hospital-based outpatient services can be
oadly classified into five main types: clinical, surgical, emergency, home health, and women’s health.
Mobile Health Care Services. Mobile health care services are transported to patients. Telephone triage, home health care, and hospice services are the three mobile facilities for medical, diagnostic, and screening services.
Public Health and Health Departments. Public health services provided by local health departments range from immunization services to a full range of outpatient services.
Alternative medicine and complementary medicine. Alternative medicine (also refe
ed to as complementary medicine, nonconventional therapies, or natural medicine) refers to the
oad domain of all health care resources— other than those intrinsic to biomedicine—to which people have access.
Decline in inpatient care and the growth of outpatient care. Medicare reimbursement and cost-saving efforts of managed care are the two main factors that have led to a decline in hospital inpatient days and a growth in ambulatory services.
In the mid-1980s, Medicare instituted the prospective payment system (PPS) for reimbursing hospitals. PPS reimbursement based on DRGs provides fixed case-based payment to hospitals. Hospitals, therefore, have a strong incentive to minimize the inpatient length of stay and continue treatment in an outpatient setting.
The outpatient sector has fewer payment restrictions. Cost-containment strategies adopted by managed care also stress lower inpatient utilization, with a co
esponding emphasis on outpatient services. These financial factors, for instance, have provided major impetus for the unprecedented growth of home health care. Such changes, coupled with the availability of new technology, have also shifted a number of inpatient surgical procedures from the inpatient to the outpatient setting.
Lesson3: Primary care
Primary care plays a very important role in the delivery of health care services in the United States. It not made up of an appointed set or list of services but rather an approach to