- primary

- secondary

-tertiary

- first hospitals: charitable organizations who sought to provide care to those they served rather than cure/rehabilitate

*care for shelter: poor, elder, orphaned, homeless, contagious, or dangerously insane

* often dirty/overcrowded

- late 180ss/early 1900s hospitals became physicians workshops

*w med & tech advances: could not bring everything they needed to homes

*large growth in # of hospitals

>1909= more than 4,300 compared to 1873 only 178

>2017= total # of hospitals 5,564, 2015: 4,862

- 2nd era of growth 1945-1980

*federal monies available to build new hospitals underthe Hill-Burton Act

*Rapid growth of hospital insurance, medicare & medicaid

-complex administrative structure, as physicians control type & amount of services they always been a key player

- traditional hospital structure includes board of directors, administrative structure, and medical staff structure

- Board of directors: retains fiduciary (legal/ethical relationships of trust) responsibility to manage & govern hospital

- Medical division:

*often headed by a physician known as chief or medical staff

*divided into divisions by specialty (surgery, internal medicine, etc.)

- therapy can be either administration OR medical division

- may have nursing division, therapy division, or therapeutic division (Nurse + rehab)

- pt focused care has resulted in reorganization of hospital sys

*organizes providers & around perceived pt needs rather than discipline

*avoids prob of poor comm & redunduncy of services

*therapists may be organized into product-ling team around common pt types (stroke, total joint, etc.)

* may use matrix system: therapists reposnible to team leader for activities/performance (clinical matters) and manager for nonclinical

-based on inpatient beds setup & staff

- most under 200

*current stats: total of bed in US 2017: 897,961

- large hospitals represent large tertiary carae centers for gen pop & indigent pop/persons in need (trauma care)

- community (non-federal acute care) 87%

- federal gov 4%

- non-federal psychiatric 7%

- non-federal LTC 2%

- hospital units of institution < 1%

1. Nonprofit organizations: nonprofit hospitals 59%

- managed by community boards or religious org

2. Owned & operated for profit corporations: investor-owned or for-profit hospitals 21%

- for-profit: dominated by national chains

- profits are distributed to its shareholders

3. owned & managed by federal, state, or local gov: public hospitals 20%

- public hospitals: primary source of care for the poor/indigent before Medicaid

*city/county hospitals, military hospitals, VA hospitals, & US public health service hospitals

*an important safety net for the poor & those not covered by private insurance

- Hybrid ownership structures:

*some hospitals have multiple owners

- General: general medicine

- Specialty: specific diseases or defined pops; children's hospital, LTC centers, rehab hospitals, mental health/psychiatric hospitals, substance abuse centers

- Acute: serve inpatients w an avg length of stay no more than 30 days, acute short-term illness

- LTC: include facilities such as nursing homes, psychiatric hospitals, rehabilitative hospitals, home health agencies

*care over a long period of time or intermittent throughout an individual's life

- acute & LTC may have common ownership & be in close proximity

- sophisticated tech & cutting edge research

- deliver large % of health care services & disproportionate share of charity & indigent care

- only 6% are members of the Council of Teaching Hospitals (COTH) & Health systems

- COTH standards:

*member hospitals must sponsor 4 approved medical residency programs

*2 of 4 programs must either be medicine, surgery, pediatrics, fam practice, OBGYN, psychiatry

- edu the nation's physicians & conduct med research while providing quality care to pts

- provides care to vulnerable pts

- hospitals provide uncompensated care (worth billions)

- typically academic medical centers& public hospitals

- funding from local, state & federal gov agencies

- Bill Medicare, Medicaid, and private insurances

* policies or env changes that impact these payment sources have greater negative impact on safety-net hospitals

*1990s-2000s HMOs gained power& negotiated lower hospital reimbursement

*Balanced Budget Act of 1997

>all reduced hospital payment w higher expenses due to operating costs

- Multihospital systems & networks

*MHS: 2 or more hospitals owned, leased or contract-managed by the same organization

*profit or not for profit, local or national

*American Hospital Association (AHA) defines alliances as formal organizations that work for benefits of members to provide services & products as well as the promotions of activities & ventures

- Professional working hospitals

*initially the physicians workshop

*today house many professions: surgeons, RN, respiratory therapist, OT, PT

- 1st level of care in US health care sys

- main entry point

- illnesses are general, episodic, common, & nonchronic in nature

- 1995: institute of Medicine defined primary care:

*provision of integrated, accessible health care service by clinicians who are accountable for addressing a large majority of personal health care need, dev a sustained partnership w pts & practicing in the context of fam & community

- physicians, internal medicine, fam medicine, pediatric, OBGYN

- therapists working in primary care:

*dev of direct access to therapy & growth of outpatient model of therapy resulted in more therapists working in disease & injury prevention, triage in ER & assessment of pt without physicians referral

*best known model is in the military

- why didn't someone explain this to me at the docto'rs office?  I would have done it if i had just understoof better?

-  OTs proposed role in primary care:

*assist physician by means of EI to prevent disease or disability

*provide holistic care focusing on symptoms impacting function

*improve pt satisfaction by addressing broad issues/concerns

*provide simple interventions that can be done @ home

*suggest activity modifications or AE/tech

*provide group edu or intervention sessions

- ACA brought changes related to primary care:

*Accountable care organizations (ACOs)

*Patient cenetered medical home (PCMH)

- can be provided in an ambulatory or inpatient basis

- more intense & often over a longer period of time than primary

- chronic conditions req continuous care

- arthritis, diabetes, hypertension

- highly specialized, complex, costly, delivered in an inpatient setting

- coronary artery bypass grafting, specialized diagnostic devices

- predominantly provided in academic medical centers

- burn units, trauma centers, transplant services

- capability to provide comprehensive care that is cost effective using a variety of delivery components & payment mechanisms

- players= insurers, MCOs, health care system, hospital, med groups

- goal: joining together achieves greater efficiency

- 4 basic models:

1. single entry sys that includes hospitals, physicians, & health plan

2. single entity delivery sys w/o the health plan

3. multiple independent providers that make up an organization that share & coordinate services

4. gov-facilitated networks of providers

- Horizontal integration:

*when 2 or more firms producing similar services joint to become a single organization

- Vertical integration:

*hospitals & physicians join to provide a continuum of care w/i a single organization

*physician-hospital relationships are sometimes called physician-hospital organization (PHOs)

= structural mechanism that facilitates integration of physicians into the mgmt & governance of the hospital & activities of the clinical-med staff

- purpose: link pt entry points to health care sys, forming continuum of services for the pt

- closer ties over the years to lower expenses & take advantage of managed care contract opportunities

- hospitals establish links to ensure a constant flow of pts are referred to them by the physicians

- important for therapist to understand the models they are working in

- overall goals/purpose: ^ leverage in negotiating manage care contracts, capital & info systems sharing, quality improvement & efficiency, creating a broad continuum of care, sharing administration expenses & ^ physician involvement in process managed care contracting

- PPACA of 2010 encourages the dev of risk-taking-physician-hospital organizations called accountable care organizations and an integrated outpatient team called the patient-centered medical home

- ACO: integrated health delivery sys that manage pops of pts across all levels of care (not required for providers)

- PCMH: coordinated ambulatory care sys compromised of pt teams led by a physician that work together to manage pops

- 5 primary features:

1. comprehensive care

2. patient-centered

3. coordinated care

4. excellent access to care

5. quality & safety

- PPACA provides $ incentive to these organizations who provide care to Medicare beneficiaries

*effect on therapists not known yet

- International prospective includes data from US: review of literature

- changing in health care to put emphasis on accountability causing mvmt of pts within healthcare to be faster

- OTs face pressure to provide care in a reductionist medical model rather than meaningful occupational engagement

- Themes:

*comparing practice of novice & experiences OTs in acute care

> novice note the importance of quality supervision is essential, but often feel they do not get it

*OTs & the d/c planning process

*role of occupation in acute care setting

*personal skills needed an organization factors affecting acute care practice

>relationships w multidisciplinary colleagues are both valuable & a source of frustration

- acute med care delivery sys towards integrated health sys to combat this change:

*both vertical & horizontal integration