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Survival strategies for nurses in managed care / [edited by] Toni G. Cesta.
Holman Biotech Commons RA413 .S87 2002
By Request
- Format:
- Book
- Language:
- English
- Subjects (All):
- Managed care plans (Medical care).
- Nursing.
- Nursing--Effect of managed care on.
- Managed Care Programs.
- Case Management.
- Nurse's Role.
- Medical Subjects:
- Managed Care Programs.
- Nursing.
- Case Management.
- Nurse's Role.
- Physical Description:
- xxii, 425 pages : illustrations ; 25 cm
- Place of Publication:
- St. Louis : Mosby, [2002]
- Summary:
- This book helps nurse managers define their role in the managed care system, learn strategies in financial management and focus on preventative care, while working on re-engineering patient care delivery systems, utilization, and outcomes management. It addresses topics from defining managed care andexplaining how a company works, to addressing ethical and legal issues that arise in the managed care system.
- Contents:
- 1 Nursing's Voice and Presence in Today's Managed Healthcare Environment / Hussein A. Tahan 3
- Overview of Managed Care 4
- Managed Care Enrollment 8
- Attributes and Characteristics of Managed Care Services 10
- Nursing's Role in Managed Care: Drivers of Change 13
- Consequences of Managed Care on Nursing: Case Management 15
- Nurses and Demand Management Programs 17
- Nurses and Managed Care Accreditation 18
- Nurses and the Advocacy Role 19
- Nursing Education and Managed Care 20
- The Future of Nurses in Managed Care 20
- 2 Historical Perspectives on Managed Care / Sandra B. Lewenson 23
- Historical Overview of Nursing 24
- The Modern Nursing Movement 25
- The Metropolitan Visiting Nurse Service 29
- Cost Analysis Study 31
- Contemporary Perspectives on Managed Care 31
- Case Managers 34
- Measuring the Value of Nursing 35
- 3 How a Managed Care Organization Works / Francesca Losito 37
- Structure: Medical Management 38
- Process: Investigating the Structure 45
- Desired Outcomes: Goals, Measurement, and Accountability 46
- Future Challenges for Managed Care Organizations 49
- 4 Fundamentals of Managed Care / Lauren Hoffmann 51
- Common Characteristics of Managed Care Plans 52
- Evaluating the Quality of Managed Care Plans 55
- Payment Model Used to Reimburse Providers 56
- Preventive Services and Other Covered Benefits 57
- Cost Versus Benefit 58
- Commitment to Quality of Care and Service 60
- Navigating the Managed Care Environment 61
- Appendix 4-1 Glossary of Managed Care Terms 61
- Appendix 4-2 Directory of Organizations Providing Managed Care Resources 67
- Part II The Business of Managed Care
- 5 Strategies for Operationalizing Managed Care: A Case Study / Laurel Nadler 71
- What Does Operationalize Really Mean? 72
- Patient Education 72
- Staff Education 76
- Managing Enrollment, Referrals, and Authorizations 80
- Ensuring Access and Continuity 82
- Credentialing Providers 84
- Developing Information Systems and Analyzing Data 87
- Managing Relationships with Managed Care Plans 89
- 6 Wall Street and Healthcare: Understanding Our New Partner / Elizabeth Corso Falter, William A. Falter, Laura A. Kukowski 90
- Traditional Healthcare Delivery Model 91
- Change in the Traditional Healthcare Delivery Model 92
- Wall Street Enters the Picture 93
- Wall Street Involves Itself in Healthcare 95
- The Impact of Wall Street on Healthcare Delivery 101
- Wall Street and the Healthcare Professional 102
- 7 Managed Care: What's Next? / Connie Burgess 105
- The Provider Viewpoint 106
- The New "Good Old Days," 107
- Back to Basics 107
- Payment Mechanisms and Incentives 108
- New Lessons on Both Sides 110
- Taking Some Risks: Moving to the Next Stage 111
- Successful Teams 112
- Framework for Thinking and Planning 112
- Continuums of Care 113
- The Future of Case Management 116
- Part III Nursing Perspectives
- 8 The Impact of Managed Care on the Staff Nurse / Elizabeth A. Bonetti 121
- The Changing Work Environment 123
- The Staff Nurse's Role and Responsibilities 130
- Do's and Don'ts for Staff Nurses 133
- Living with Change: Opportunities 133
- 9 Nurse Practitioners and Managed Care / Diana J. Mason, Jeffrey P. O'Donnell 137
- Evolution of the Nurse Practitioner in Managed Care 138
- Managed Care Organizations' Arrangements with Nurse Practitioners 141
- Barriers to Managed Care Organizations' Full Utilization of Nurse Practitioners 144
- Surviving the Managed Care Environment 148
- Challenging the System 152
- 10 The Role of the Chief Nurse Executive in Managed Care / Christine Coughlin 154
- Role of the Chief Nurse Executive 155
- Alignment with the Mission of the Hospital 155
- Case Study: The Chief Nurse Executive at Montfiore Medical Center 155
- Capitation Has Its Risks 156
- GRIP 156
- Managed Care Readiness Work Groups 158
- Early Preparation for Managed Care 160
- Nursing Governance 161
- Care Delivery Model 163
- Balanced Scorecard 164
- Opportunities for Nursing 166
- 11 Person and Community: Coauthors of Health and Care / Sandra Schmidt Bunkers 168
- The Call to Community 169
- Core Components for Creating a Theory-Based Nursing Practice Model 170
- Processes of Theory-Based Nursing Model Development 174
- 12 Nurse/Physician Partnerships: Essential to Care Management? / Ruth A. Hanson 180
- In the Beginning 181
- Organization Design Process and Criteria 182
- Managed Care: A Subset of Care Management 184
- Care Management and Nurse/Physician Partnerships at MeritCare Health System 185
- Properties and Principles of Partnership 185
- So Where Are We, Really? Actualized Vision, Fairy Tale, or Somewhere In Between? 186
- Future Directions 194
- Appendix 12-1 Who is MeritCare Health System? 195
- 13 Integrating Concepts of Managed Care and Nursing Case Management into Academic Curricula / Patricia A. Chin, Judith L. Papenhausen 196
- Literature Review 198
- Curriculum Development and Design 199
- Associate Degree Curriculum 200
- Baccalaureate Degree Curriculum 203
- Masters Degree Curriculum 208
- Doctoral Level Curriculum 213
- Appendix 13-1 Sample Baccalaureate Theory Course Syllabus 215
- Appendix 13-2 Sample Baccalaureate Clinical Course Syllabus 216
- Part IV Legal and Ethical Issues
- 14 Legal Issues in Managed Care / Barbara A. Ryan, Tina H. Sernick 221
- Underlying Principles 221
- Legal Issues 223
- Statutory Schemes 227
- 15 Managed Care and the Nurse: Legal Issues / Margaret Davino 233
- Payment Methods 234
- Receiving Nonreimbursed Care 235
- Frequently Asked Questions About Legal Issues in Managed Care 235
- 16 Ethics, Integrity, and Managed Care / Carol Taylor 249
- The Broad Ethical Challenges Posed by Managed Care 250
- Trends in Healthcare Delivery in the United States 251
- Fee-for-Service and Managed Care Arrangements 256
- The Major Ethical Challenges Related to Managed Care 257
- Attempts to Identify the Nonnegotiables of Moral Healthcare 261
- Practical Recommendations for Reflection and Action 262
- 17 Nursing Ethics in a Managed Care Environment / Ellen R. Mitchell 264
- Changing Times 264
- Patient Rights 265
- The Role of the Hospital-Based Nurse Case Manager 266
- The Difference Between Ethics and the Law 267
- Practical Application of Ethical Constructs 270
- Part V Strategies for Success in a Managed Care Environment
- 18 A Systems Approach to Hospital-Based Nursing Case Management / Laurie J. Frahm, Linda Hertz 279
- Current Environment 281
- The Model 282
- Outcomes of Nursing Case Management 286
- Barriers to Systemwide Nursing Case Management 288
- Improvements for the Future 288
- 19 Community-Based Health Programs in a Managed Care Environment / Mary Krentzman 290
- The Chronically Ill 291
- Community Case Management 291
- Identification Process 293
- Group Programming 297
- Financial Outcomes 299
- Clinical Outcomes 299
- Satisfaction Measurements 300
- Community Case Management in Action 301
- 20 Quality Management in a Managed Care Environment / Eileen Barton 306
- Current State of Healthcare Quality 307
- Evolution of Quality Management 308
- Quality Management in Managed Care 311
- Managed Care Regulation and Accreditation 317
- Quality Management in the Twenty-First Century 320
- 21 Strategies for Accessing and Analyzing Meaningful Information / Lisa M. Zerull 322
- Rationale for Analysis 323
- Data Elements/Indicators for Analysis 325
- Accessing Information 327
- The Who of Data Analysis? 329
- Outcomes Analysis for Specified Patient Population(s) 331
- Other Considerations for Success with Data Analysis 336
- The Future 337
- 22 Utilization Management / Susan M. Erickson 339
- Hospital-Based Utilization Review/Management 340
- Payer-Based Utilization Review/Management 352
- 23 Outcomes Management in a Managed Care Environment / Lawrence F.
- Strassner 357
- Outcomes Management Defined 358
- Case Management and Outcomes Management 358
- Case Managers Improve Cost, Clinical, and Satisfaction Outcomes 358
- Satisfaction with Care 359
- Performance Measures 359
- Case Managers Manage Cost of Care 363
- Case Managers Improve Clinical Outcomes 369
- Case Managers Improve Service and Satisfaction Outcomes 372
- 24 Disease Management in Managed Care / Donna Zazworsky 376
- Theoretical Models 377
- Elements of Disease Management 379
- The FAST Approach to Disease Management 392
- Nursing Case Management Implications 395
- 25 Workers' Compensation in Managed Care / Deborah V. DiBenedetto 398
- Financial Impact of Workers' Compensation 399
- Integrated Benefit Initiatives and Impact on Workers' Compensation Programs 399
- Utilization Review and Quality Assurance 405.
- Notes:
- Includes bibliographical references and index.
- ISBN:
- 032301397X
- OCLC:
- 48958210
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