Health Deliver- Lead
100honestyworkInpatient and Outpatient Services
LEARNING OBJECTIVES
The student will be able to:
Identify and discuss three milestones of the history of the hospital.
Define and discuss the different hospitals by their ownership classification.
Describe the difference between hospitals by who they serve.
Identify the different types of outpatient care settings.
Analyze the utilization trends of both inpatient and outpatient services.
Evaluate the difference between inpatient and outpatient services.
DID YOU KNOW THAT?
Hospitals are the foundation of our healthcare system.
Other terms related to “hospital” include hospitality, host, hotel, and hospice.
Voluntary hospitals are called voluntary because their funding comes from the community voluntarily.
According to the Urgent Care Association, ownership of urgent care centers is split fairly evenly among physicians (35.4%), corporations such as private investors and insurers (30.5%), and hospitals (25.2%). Women seek healthcare services more frequently than men.
Public hospitals are the oldest type of hospital and are government owned.
Religious hospitals were developed as a way to perform spiritual work.
INTRODUCTION
Inpatient services are services that involve an overnight stay of a patient. Historically, the U.S. healthcare industry was based on the provision of inpatient services provided by hospitals and outpatient services provided by physicians. As our healthcare system evolved, hospitals became the mainstay of the healthcare system, offering primarily inpatient with limited outpatient services. Over the past 2 centuries, hospitals have evolved from serving the poor and homeless to providing the latest medical technology to serve the seriously ill and injured (Shi & Singh, 2008). Although their original focus was inpatient services, as a result of cost containment and consumer preferences, more outpatient services are now being offered by hospitals. Hospitals have evolved into medical centers that provide the most advanced service. Hospitals can be classified by who owns them, length of stay, and the type of services they provide. Inpatient services typically focus on acute care, which includes secondary and tertiary care levels that most likely require inpatient care. Inpatient care is very expensive and, throughout the years, has been targeted for cost containment measures. Hospitals have begun offering more outpatient services that do not require an overnight stay and are less financially taxing on the healthcare system. U.S. healthcare expenditures have increased as part of the gross domestic product, and consequently, more cost containment measures have evolved. Outpatient services have become more popular because they are less expensive and they are preferred by consumers. This chapter will discuss the evolution of outpatient and inpatient healthcare services in the United States.
HISTORY OF HOSPITALS
The word hospital comes from the Latin word hospes, which means a visitor or host who receives a visitor. From this root word, the Latin hospitalia evolved, which means an apartment for strangers or guests. The word hospital was a word in the Old French language. As it evolved, in the 15th century, England shifted the meaning to a home for the infirm, poor, or elderly. The modern definition of “an institution where sick or injured are given medical or surgical care” was developed in the 16th century. The name Hôtel-Dieu, "the hotel of God," was commonly given to hospitals in France during the Middle Ages (American Hospital Association, 2013).
Over 5,000 years ago, Greek temples were the first type of hospital with similar institutions in Egyptian, Hindu, and Roman cultures (Longest & Darr, 2008). They were the precursor of the almshouses or poorhouses that were developed in the 1820s to primarily serve the poor. Hospitals provided food and shelter to the poor and consequently treated the ill. Pesthouses, operated by local governments, were used to quarantine people who had contagious diseases such as cholera. The framework of these institutions set up the concept of the hospital. Initially, wealthy people did not want to go to hospitals because the conditions were deplorable and the providers were not skilled, so hospitals, which were first built in urban areas, were used by the poor. In 1789, the Public Hospital of Baltimore was established for the indigent and, in 1889, it became Johns Hopkins Hospital, which exists today as one of the best hospitals in the world (Sultz & Young, 2006). In the 1850s, a hospital system was finally developed, but the conditions were deplorable because of the staff of unskilled providers. Hospitals were owned primarily by the physicians who practiced in them (Relman, 2007), and therefore became more cohesive among providers because they had to rely on each other for referrals and access to hospitals, which gave them more professional power (Rosen, 1983).
In the early 20th century, with the establishment of standardized medical education, hospitals became accepted across socioeconomic classes and developed into the symbol of medicine. With the establishment of the American Medical Association (AMA) that protected the interests of providers, the reputation of providers became more prestigious. In the 1920s, because of the development of medical technological advances, increases in the quality of medical training and specialization, and the economic development of the United States, the establishment of hospitals became the symbol of the institutionalization of health care and the acknowledgment of the medical profession as a powerful presence (Torrens, 1993). During the 1930s and 1940s, the ownership of hospitals changed from physician-owned to church-related and government operated (Starr, 1982). Religious orders viewed hospitals as an opportunity to perform their spiritual good works, so religion played a major role in the development of hospitals. Several religious orders established hospitals that still exist today.
In 1973, the first Patient Bill of Rights was introduced to represent the healthcare consumer in hospital care (AHA, 2013a). In 1972, the AHA had all hospitals display a “Patient Bill of Rights” in their institutions (Sultz & Young, 2006). In 1974, the National Health Planning and Resources Development Act required states to have certificate of need (CON) laws to ensure the state approved any capital expenditures associated with hospital/medical facilities’ construction and expansion. The Act was repealed in 1987, but as of December 2011, 36 states still have some type of CON mechanism (National Conference of State Legislatures, 2013). The concept of CON was important because it encouraged state planning to ensure their medical system was based on need.
Hospitals are the foundation of our healthcare system. As our health insurance system evolved, the first type of insurance was hospital insurance. As society’s health needs increased, expansion of different medical facilities increased. There was more of a focus on ambulatory or outpatient services because U.S. healthcare consumers prefered outpatient services and, secondly, it was more cost-effective. In 1980, the AHA estimated that 87% of hospitals offered outpatient surgery (Duke University Libraries, 2013). Although hospitals are still an integral part of our healthcare delivery system, the method of their delivery has changed. “Hospitalists,” created in 1996, are providers that focus specifically on the care of patients when they are hospitalized (Nabili, 2013). This new type of provider recognized the need of providing quality hospital care. More hospitals have recognized the trend of outpatient services and have integrated those types of services into their delivery. In 2000, as a result of the Balanced Budget Act cuts of 1997, the federal government authorized an outpatient Medicare reimbursement system, which has supported hospital outpatient services efforts. In 2010, hospitals employed approximately 5 million employees, received over 600 million outpatient visits and 130 million visits to their emergency departments, and performed 27 million surgeries of which 60% were outpatient surgeries (American Hospital Association, 2012a).
HOSPITAL TYPES BY OWNERSHIP
There are three major types of hospitals by ownership: (1) public, (2) voluntary or community, and (3) proprietary hospitals. Public hospitals are the oldest type of hospital and are owned by the federal, state, or local government. Federal hospitals generally do not serve the general public but operate for federal beneficiaries such as military personnel, veterans, and Native Americans. The Veterans Affairs (VA) hospitals are the largest group of federal hospitals. They have high utilization rates by veterans. Taxes support part of their operations. In 2011, there were 208 federal hospitals. County and city hospitals are open to the general population and are supported by taxes. Many of these hospitals are located in urban areas to serve the poor and the elderly. Larger public hospitals may be affiliated with medical schools and are involved in training medical students and other healthcare professionals (Shi & Singh, 2008). Their services are primarily reimbursed by Medicare and Medicaid services and have high utilization rates. In 2011, there were 1,045 state and local hospitals (AHA, 2013b).
Voluntary hospitals are not government owned, private, and not-for-profit. They are considered voluntary because their financial support is the result of community organizational efforts. Their focus is their community. Private, not-for-profit hospitals are the largest group of hospitals. In 2011, there were nearly 3,000 not-for-profit hospitals. Proprietary hospitals or investor-owned hospitals are for-profit institutions and are owned by corporations, individuals, or partnerships. Their primary goal is to generate a profit. They have the lowest utilization rates. In 2011, there were 1,025 proprietary hospitals (AHA, 2013b).
HOSPITAL TYPES BY SPECIALTY
Hospitals may be classified by what type of services they provide and their target population. A general hospital provides many different types of services to meet the general needs of its population. Most hospitals are general hospitals. Specialty hospitals provide services for a specific disease or target population. Some examples are psychiatric, children’s, women’s, cardiac, cancer, rehabilitation, and orthopedic hospitals.
OTHER HOSPITAL CLASSIFICATIONS
Hospitals can be classified by single- or multiunit operations. Two or more hospitals may be owned by a central corporation. Multiunit hospitals are the result of the merging or acquiring of other hospitals that have financial problems. These chains can be operated as for-profit, not-for-profit, or government owned. These hospitals often formed systems because it was more cost-efficient. In 2011, there were over 3,000 hospital systems. Hospitals can also be classified by length of stay. A short stay or acute care hospital focuses on patients who stay on an average of less than 30 days. Community hospitals are short term. A long-term care hospital focuses on patients who stay on an average of more than 30 days. Rehabilitation and chronic disease hospitals are examples of long-term care hospitals. More than 90% of hospitals are acute or short-term (AHA, 2013b).
Hospitals can be classified by geographic location—rural or urban. Urban hospitals are located in a county with designated urban or city geographic areas. Rural hospitals are located in a county that has no urban areas. In 2011, there were 1,984 rural community hospitals. Urban hospitals tend to pay higher salaries and consequently offer more complex care because of the highly trained providers and staff. In 2011, there were nearly 3,000 urban hospitals. Rural hospitals tend to see more poor and elderly and, consequently, have financial issues (AHA, 2013b). As a result of this issue, the Medicare Rural Hospital Flexibility Program (MRHFP) was created as part of the Balanced Budget Act of 1997. The MRHFP allows some rural hospitals to be classified as critical access hospitals if they have no more than 25 acute care beds and provide emergency care and are eligible for grants to increase access to consumers. This classification enables them to receive additional Medicare reimbursement called cost plus. Cost plus reimbursement allows for capital costs, which enables these facilities to expand (Centers for Medicare & Medicaid Services [CMS], 2013).
Teaching hospitals are hospitals that have one or more graduate resident programs approved by the AMA. Academic medical centers are hospitals organized around a medical school. There are approximately 400 teaching hospitals that are members of the Council of Teaching Hospitals and Health Systems in the United States and Canada. These institutions offer substantial programs and are considered elite teaching and research institutions affiliated with large medical schools (Association of American Medical Colleges, 2013).
As discussed previously, church-related hospitals are developed as a way to perform spiritual work. The first church-affiliated hospitals were established by Catholic nuns. These hospitals are community general hospitals. They could be affiliated with a medical school. Osteopathic hospitals focus on a holistic approach to care. They emphasize diet and environmental factors that influence health as well as the manipulation of the body. Their focus is preventive care. Historically, osteopathic hospitals were developed as a result of the antagonism between the different approaches to medicine—traditional or allopathic medicine versus holistic. Current trends indicate that both branches of medicine now serve in each others’ hospitals and respect the focus of each others’ treatment (Shi & Singh, 2008).
HOSPITAL GOVERNANCE
Hospitals are governed by a chief executive officer (CEO), a board of trustees or board of directors, and the chief of medical staff. The CEO or president is ultimately responsible for the day-to-day operations of the hospital and is a board of trustee’s member. CEOs provide leadership to achieve their mission and vision. The board of trustees is legally responsible for hospital operations. It approves strategic plans and budgets and has authority for appointing, evaluating, and terminating the CEO. Boards often form different committees such as quality assurance, finance, and planning. In a recent AHA survey, the CEOs indicated the two standing committees were finance and quality. Economic conditions and legal requirements have forced boards to become more goal oriented and have developed very specific objectives that also focus on quality and safety as well as finances. Hospital governance has evolved as hospital structures have changed. There are more hospitals that belong to a system of hospitals with one board that oversees the system making the individual hospital boards’ subsidiary boards (Totten, 2012).
The chief of medical staff or medical director is in charge of the medical staff/physicians that provide clinical services to the hospital. The physicians may be in private practice and have admitting privileges to the hospital and are accountable to the board of trustees. The medical staff is divided according to specialty or department, such as obstetrics, cardiology, radiology, etc. There may be a chief of service that leads each of these specialties. There is also the operational staff that is a parallel line of staff with the medical staff. They are responsible for managing nonmedical staff and performing nonclinical, administrative, and service work (Longest & Darr, 2008; Pointer et al., 2007). It is in the best interest of the institution that both the operational staff and medical staff collaborate to ensure smooth management of the facility.
The medical staff also have committees such as a credentials committee that reviews and grants admitting privileges to physicians, a medical records committee that oversees patient records, a utilization review committee that ensures inpatient stays are clinically appropriate, an infection control committee that focuses on minimizing infections in the hospital, and a quality improvement committee that is responsible for quality improvement programs (Shi & Singh, 2008).
HOSPITAL LICENSURE, CERTIFICATION, AND ACCREDITATION
State governments oversee the licensure of healthcare facilities including hospitals. States set their own standards. It is important to note that all facilities must be licensed but do not have to be accredited. State licensure focuses on building codes, sanitation, equipment, and personnel. Hospitals must be licensed to operate with a certain number of beds.
Certification of hospitals enables them to obtain Medicare and Medicaid reimbursement. This type of certification is mandated by the Department of Health and Human Services (DHHS). All hospitals that receive Medicare and Medicaid reimbursement must adhere to conditions of participation that emphasize patient health and safety. Accreditation is a private standard developed by accepted organizations as a way to meet certain standards. For example, accreditation of a hospital by The Joint Commission (TJC) means that hospitals have met Medicare and Medicaid standards and do not have to be certified. Medicare and Medicaid have also authorized the American Osteopathic Organization to jointly accredit their types of hospitals with TJC (TJC, 2013 a). It is important to mention that TJC has had tremendous impact on how healthcare organizations are accredited. Since its formation in 1951, TJC has expanded its accreditation beyond hospitals. They accredit ambulatory care, assisted living, behavioral health care, home care, hospitals, laboratory services, long-term care, and office-based surgery centers. Accreditation of managed care organizations such as preferred providers and managed behavioral organizations ended in 2006 (The Joint Commission, 2013b).
International Organization for Standardization
Established in 1947 in Geneva, Switzerland, the International Organization for Standardization (ISO) is a worldwide organization that promotes standards from different countries. Although this is not an accrediting organization, those organizations that register with the ISO are promoted as having higher standards. ISO 9000 (quality management focus) and ISO 14000 (environmental management focus) are management standards that are applicable to any organization, including healthcare organizations, and many healthcare organizations are registered with the ISO. For example, the ISO has standards for healthcare informatics and medical devices (ISO, 2013).
PATIENT RIGHTS
The Patient Self-Determination Act of 1990 requires hospitals and other facilities that participate in the Medicare and Medicaid programs to provide patients, upon admission, with information on their rights; it is also referred to as the Patient Bill of Rights. If you enter any hospital, you will see the Bill of Rights posted on its walls. This law requires that the hospital maintain confidentiality of its personal and medical information. Patients also have the right to be provided accurate and easy-to-understand information about their medical condition so they may give informed consent for any of their medical care.
The Affordable Care Act (ACA) created an additional Patient Bill of Rights that focuses on implementing consumer-oriented practices from insurance companies, which will help children and adults with pre-existing conditions to obtain and keep insurance coverage, to end lifetime reimbursement limits on healthcare insurance reimbursements, and to increase the opportunities for consumers to choose their physicians (Fact Sheet, 2013).
CURRENT STATUS OF HOSPITALS
Many hospitals have experienced financial problems. As a result of the increased competition of outpatient services (which are often more cost-effective, efficient, and consumer friendly) and reduced reimbursement from Medicare and Medicaid, many hospitals have developed strategies to increase their financial stability. Due to pressure to develop cost containment measures, hospitals are forming huge systems and building large physician workforces. In order to compete with the ACA’s mandated state health insurance marketplaces where consumers can purchase health insurance, health insurance companies are developing relationships with hospitals, creating joint marketing plans, and sharing patient data (Matthews, 2011).
Over the years, outpatient services have become the major competitors of hospitals. Advanced technology has enabled more ambulatory surgeries and testing, which has resulted in the development of many specialty centers for radiology and imaging, chemotherapy treatment, kidney dialysis, etc. These services were often performed in a hospital. What is even more interesting is that physicians or physician groups own some of the centers. They are receiving revenue that used to be hospital revenue. Hospitals have recognized that fact and have embraced outpatient services as part of their patient care. Hospitals have to continue to focus on revenue generation by operating more outpatient service opportunities; they own 25% of urgent care centers in the United States, 21% have ownership interest in ambulatory surgery centers, and 3% have sole ownership of outpatient centers (ASCA, 2013a).
Cost Containment Approaches
Hospitals are employing different methods to improve quality and control costs.
They use the following models:
Lean: Based on the Toyota model, this model focuses on increasing efficiency while reducing waste. Staff identify patient care processes that are inefficient and revise them to improve patient care.
Six Sigma: A Motorola approach that uses statistics to identify and eliminate defects in patient care.
Plan Do Study Act (PDSA): Developed by the Institute for Healthcare Improvement, a four-step cycle that focuses on improvement of workflow.
Providers plan a change in a workflow, and once the change is implemented, they describe what happened with the change, describe the impact of the change, observe and learn from the change, and act upon the change.
Many of the large U.S. hospitals are working with the Joint Commission Center for Transforming Healthcare to implement processes that target safe and quality patient care. For example, the PSDA can be used to reduce medication errors by analyzing the process of providing medications, determining what changes need to be made, and assessing if the changes were successful by the reduction of medication errors (American Hospital Association, 2012b).
OUTPATIENT SERVICES
As discussed previously, outpatient services are services that are provided that do not require an overnight stay. Often, the term ambulatory care is used interchangeably with outpatient services. Ambulatory literally means a person is able to walk to receive a service, which may not always be necessarily true. The term outpatient is a more general term for services other than inpatient services (Jonas, 2003). Hospitals also offer outpatients service in their emergency departments and their outpatient clinics.
Physician Offices
The basic form of an outpatient service is a patient seeing his or her physician in the physician’s office. Both general practitioners and specialists offer ambulatory care as either solitary practitioners or in group practice. Traditionally, physicians established solitary practices, but the cost of running a practice became too expensive so more physicians have established group practices (Pointer et al., 2007).
Hospital Emergency Services
Hospital emergency medical services are an integral part of the American healthcare system. Emergency departments provide care for patients with emergency healthcare needs. There were 130 million emergency department visits in 2010, accounting for about 4% of all healthcare spending in the United States (CDC, 2013a). Emergency department use is more likely among the poor, those in fair or poor health, the elderly, infants and young children, and those with Medicaid coverage (CDC, 2013b,). Hospitals traditionally provide inpatient services, though nearly all community hospitals provide emergency services that are considered outpatient services. Although emergency departments have the technology to treat emergency situations, many emergency rooms are used for nonemergency issues.
Hospital-Based Outpatient Clinics
Many outpatient clinics are found in teaching hospitals. They use outpatient clinics as an opportunity to teach and perform research. The clinics are categorized as surgical, medical, and other. Larger teaching hospitals may have 100 specialty and subspecialty clinics (Jonas, 2003). They may operate as part of the hospital or as a hospital-owned entity.
Urgent/Emergent Care Centers
Urgent/emergent care centers were first established in the 1970s, and are used for consumers who need medical care but their situation is not life-threatening. This would take the place of the hospital emergency room visit. The medical issue usually occurs outside traditional physician office hours so they see patients in the evenings and on weekends and holidays. Many of these centers are both walk-in and appointment facilities. They do not take the place of a patient’s primary care provider. These centers are conveniently located and may be in strip malls or medical buildings so they are accessible for consumers. It is important to note that many managed care organizations will reimburse member visits because they are less expensive than an emergency room visit (Sultz & Young, 2006). The urgent care centers relieve the emergency departments from seeing patients who do not have life-threatening situations. It is anticipated that there will be an increase in urgent care centers because of this need.
The number of new urgent care centers has increased for a total of 9,000 nationwide in 2012. Physicians (35.4%), private investors and insurers (30.5%), and hospitals (25.2%) are the top three owners of urgent care centers. Private equity firms have invested nearly $4 billion in healthcare services in 2013, fueled predominantly by urgent care centers. This type of medical care has become the consumer preference because there is less wait time than an emergency room visit (Dolan, 2013). According to an Urgent Care Association of America (UCAOA) survey, approximately 85% of the centers have a physician on site at all times, and 75% of the physicians are board certified in a primary specialty (UCAOA, 2013).
Ambulatory Surgery Centers
Ambulatory surgery centers (ASCs) are for surgeries that do not require an overnight stay. Physicians have taken the lead in developing ASCs. The first ASC was established in 1970. It provided an opportunity for physicians to have more control over their surgical practices as they grew frustrated by hospital policies, wait times for surgical rooms, and delays in new equipment. Advances in technology and newer anesthesia drugs to help patients recover more quickly from grogginess have enabled more surgeries to be performed on an outpatient basis. ASCs may focus on general surgical procedures that involve the abdomen, whereas specialized surgical centers focus on orthopedic surgery, plastic surgery, and gynecologic surgery. Some centers offer a combination of both general and specialized surgeries. Outpatient surgery is a major contributor to growth in ambulatory care. Approximately 8 million surgeries are performed in 4,000 ASCs annually. The most common procedures include ophthalmology; gastroenterology; orthopedic; ear, nose, and throat; gynecology; and plastic surgery. ASCs contribute to healthcare cost containment. Procedures at ASCs cost nearly 50% less than inpatient surgeries. Hospitals have ownership interest in 21% of ASCs and have sole ownership in 3% of ASCs. Patient surveys indicate over 90% customer satisfaction with their care and service (ASCA, 2013). Health Centers (HCs), which originated in the 1960s as part of the war on poverty, are organizations that provide culturally competent primary healthcare services to the uninsured or indigent population such as minorities, infants and children, patients with HIV, substance abusers, the homeless, and migrant workers. They are supported by the Health Resources and Services Administration (HRSA) and operate on four fundamentals:
1. Location in high service need community
2. Governed by a community board
3. Provide comprehensive primary care
4. Must achieve performance objectives (HRSA, 2013b)
HCs often are located in urban and rural areas where there is a designated need. They enter a contract with the state or local health department to provide services to these populations. They also provide links with social workers, Medicaid, and Health Insurance Program (HIP). As part of the ACA, funding increased for HCs. Grants were awarded to 219 health centers to expand access to care for more than 1.25 million additional patients and create approximately 5,640 jobs by establishing new health center service delivery sites (DHHS, 2012a). HCs may be organized as part of the local health department or other health service; they also operate at schools. In 2011, over 1,000 HCs received federal funding, providing care to over 20 million patients. HCs provide more preventive services than primary care providers such as healthcare education, mammograms, pap smears, and adult immunizations (DHHS, 2013b).
Home Health Agencies
Home health agencies and visiting nurse agencies provide medical services in a patient’s home. The earliest form of home health care was developed by Lillian Wald, who created the Visiting Nurse Service of New York in 1893 to service the poor. In 1909, she persuaded the Metropolitan Life Insurance Company to include nursing home care in their policies (Longest & Darr, 2008). This care is often provided to the elderly, disabled, or a patient who is too weak to come to the hospital or physician’s office or has just been released from the hospital. Contemporary home health services include both medical and social services, incorporating skilled nursing care and home health aide care such as dispensing medications, assisting with activities of daily living, and meal planning. Physical, speech, and occupational therapy can also be provided at home. Medical equipment such as oxygen tanks, hospital beds, etc., may also be provided. Annually, approximately 7 million people receive home health services that are provided by approximately 20,000 agencies. These agencies can be private not-for-profit, government, or private for-profit (Longest & Darr, 2008).
Although the home healthcare industry is very popular with patients, there have been continued problems with the quality of home health care being offered, as well as issues with fraudulent Medicare reimbursement for services not needed. Although most states offer licensing for home health agencies, it is important that home health agencies are Medicare certified because they are required to comply with CMS regulations. In 2011, about 3.4 million Medicare beneficiaries received home health services from almost 11,900 home health agencies. Access to home health care is generally adequate: 99% of beneficiaries live in a ZIP code where a Medicare home health agency operates, and 98% live in an area with two or more agencies. There were 12,000 agencies in 2011. In 2011, Medicare implemented two major changes to strengthen program integrity for Medicare home health services. In April 2011, CMS implemented an ACA requirement for a face-to-face encounter with a physician or nurse practitioner when home health care is ordered. They can also receive accreditation from the Community Health Accreditation Program (CHAP) (Medpac, 2012).
Employee Assistance Programs
Employee assistance programs (EAPs) are a type of occupational health program. Established in the 1970s as an intervention for employee drug and alcohol abuse, the program has expanded to offer other services such as tobacco cessation programs and mental health counseling and referrals. EAP services have expanded to include disease management and prevention health (Employee Assistance Programs, 2013).
OTHER HEALTH SERVICES
Respite Care
Often, family and friends of chronically ill patients become the major caregivers of their friends and family. This continuous care can become stressful for those caregivers. These caregivers may still be working full-time and have other family members that need their attention. As a result of this issue, respite care or temporary care programs were formally established in the 1970s to provide systematic relief to those caregivers who need a mental break. It also forestalls the ill patient from being placed in a facility. There are a variety of programs that are considered respite programs, such as adult day care, furloughs to facilities for the patient, and in-home aides. Long-term care insurance may pay for a portion of respite care (DHHS, 2010).
Hospice
Hospice care provides care for patients who have a life-threatening illness and comfort for the patient’s family. Medicare, private health insurance, and Medicaid (in 43 states) cover hospice care for qualified patients. Some hospice programs offer healthcare services on a sliding fee scale basis for patients with limited resources. A typical hospice care team includes the following:
Doctors
Nurses
Home health aides
Clergy or other spiritual counselors (e.g., minister, priest, rabbi)
Social workers
Volunteers
Occupational, physical, and/or speech therapists
The family of the terminally ill patient is also involved in the care giving. Hospice services can be offered both as inpatient and outpatient services. Hospitals may have designated hospice units. Home health agencies may also offer a hospice program. Medicare, Medicaid, Department of Veterans Affairs, and private insurance plans will pay for hospice services. Donations allow hospice care facilities to provide care at no cost to those who cannot afford it (WebMD, 2012).
Adult Day Care
Adult day care centers are day programs that provide a medical model of care with medical and therapeutic services; a social model that provides meals, recreation, and some basic medical health; or a medical–social model that provides social interaction and intensive medical-related activities, all depending on the needs of the patients. Adult day care centers were developed in the 1960s based on research that indicated that they were an opportunity to provide a break for informal caregivers as well as provide an opportunity to prolong the patient’s life at home. The average age of the adult day care center recipient is 72 years old and two-thirds are female (DHHS, 2012).
In 1979, the National Adult Day Services Association (NADSA) was formed to promote these types of community services. They established national standard criteria for the operation of adult day care centers. Many adult day care centers are regulated by state licensing and may be certified by a particular community agency. In 2010, there were 5,000 adult day care centers, with a national average rate of $61 per day (includes 8–10 hours on average) compared to an average rate for home health aides of $19 per hour. They are often affiliated with larger formal healthcare or skilled nursing care facilities, medical centers, or senior organizations (NADSA, 2013).
Senior Centers
Established by the Older American Act of 1965, senior centers provide a broad array of services for the older population. Services provided include meal and nutrition programs, education, recreational programs, health and wellness programs, transportation services, volunteer opportunities, counseling, and other services.
According to 2010 statistics, there are 11,000 senior centers in the United States, serving approximately 1 million seniors every day; users spend 3 hours per day, 1 to 3 times per week, at the centers; 70% of users are women; and the average age of attendees is 75 years of age (National Council on Aging [NCOA], 2013). Funding is received from state and local governments, grants, and private donations.
Located in Washington, D.C., NCOA is a not-for-profit advocacy agency for the senior population. As part of the NCOA, the National Institute of Senior Centers (NISC) is a network of senior center professionals that promote senior centers. It is the only national program dedicated to the welfare of senior centers. It sponsors a national voluntary accreditation program for senior centers (NCOA, 2013). With the estimated increase in life expectancy, senior centers will continue to expand and offer more services to seniors who have chronic disease that can be managed on an outpatient basis.
Women’s Health Center
Women have unique health needs that require specialized medical facilities. Recognizing this need, in 1991, HHS established an Office of Women’s Health (OWH). There are currently 10 regional offices that oversee women’s health activities nationwide. Women’s life expectancy is approximately 7 years longer than men’s and will represent a larger portion of the elder population. The OWH mission is to promote women’s and girls’ health by gender-specific health activities (DHHS, 2013a).
Meals on Wheels of America
Established in 1954, the Meals on Wheels Association of America (MOWAA) is the oldest and largest national organization composed of and representing 5,000 community-based Senior Nutrition Programs that are members of the association. These programs provide well over 1 million meals to seniors who need them each day. Some programs serve meals at senior centers, some deliver meals directly to the homes of seniors whose mobility is limited, and many provide both services. Federal funding for Meals on Wheels is provided by the Senior Nutrition Program that was authorized by the 1972 Older Americans Act. In October of 2011, the U.S. Administration on Aging (AoA) entered into a cooperative agreement with MOWAA to establish a new National Resource Center on Nutrition and Aging. The primary role of the National Resource Center’s (NRC) AoA-MOWAA is to cultivate innovative ideas related to nutrition and aging in the United States (MOWAA, 2013).
In 2010, MOWAA received a large donation of $5 million from the Walmart Foundation in the fall of 2010 for the We Are Meals on Wheels Project. The We Are Meals on Wheels Project consists of four major components: (1) Walmart Foundation—MOWAA Building the Future Grants Program, (2) We Are Meals on Wheels National Multimedia Public Awareness Campaign, (3) Walmart Foundation Institute for Senior Nutrition Education, and (4) MOWAA State-Affiliate Training Wheels Program (Walmart, 2013).
Planned Parenthood Federation of America
Planned Parenthood Federation of America (PPFA) is a 90-year-old organization that provides family services to men, women, and teens in local communities regarding sexual health, family planning, and more, both online and at sites across the United States. PPFA also provides important health education to over 1 million individuals. They accept Medicaid but also offer services based on a sliding fee scale (PPFA, 2013). PPFA is a founding member of the International Planned Parenthood Federation.
American Red Cross
Founded in 1881 and headquartered in Washington, D.C., the American Red Cross (ARC) provides emergency response to victims of war and natural and manmade disasters. They also offer services to the indigent and the military, analyze and distribute blood products, provide education, and organize international relief programs. Approximately 91 cents of every dollar spent is invested in humanitarian programs. There are over 700 local chapters with 35,000 employees supported by 500,000 volunteers (ARC, 2013).
PPFA and ARC are examples of the types of outpatient services offered in different communities across the United States. Organizations have recognized that outpatient services are preferred by healthcare consumers and are cost effective. Many physicians have established outpatient services as a way to satisfy consumer preference.
Doctors Without Borders
Established in 1971 by physicians and journalists in France, Doctors Without Borders is an international medical organization that provides quality medical care to those individuals threatened by violence, catastrophe, lack of health care, natural disasters, epidemics, or wars in 60 countries. Nearly 90% of their funding is from private sources. Staff is derived from the communities where the crises are occurring as well as U.S. aid workers. The organization won the Nobel Peace Prize in 1999. A U.S. component of this organization was established in 1990, and recently raised $133 million in funding. In 2010, it sent U.S.-based aid workers on more than 430 assignments overseas (Doctors Without Borders, 2013).
Remote Area Medical Volunteer Corps
Remote Area Medical (RAM) was founded in 1985 to develop a mobile efficient workforce to provide free health care to areas of need worldwide. The first services delivered by Remote Area Medical Volunteer Corps in the United States were in the Appalachian Mountains of the Southeast, where 42% of the population is classified as rural, as compared to the national average of 20%. Volunteer physicians, nurses, and other healthcare professionals provide general medical, surgical, eye, dental, and veterinary care to thousands of individuals worldwide. However, 60% of their services are provided to the United States. RAM determines where the centers are needed the most and set up a mobile healthcare unit for weekend services only. RAM established a foundation in 1996 for the sole purpose of raising funds for RAM activities (RAM, 2013).
Telemedicine
According to the HRSA Rural Health, telemedicine or telehealth uses technology for providing healthcare services and is an efficient method of providing outpatient care. Telemedicine is a new model for delivering health care—it moves information electronically to consumers quickly and efficiently without a patient physically seeing a healthcare provider. Telemedicine uses electronic information and telecommunication technologies to support long-distance clinical health care, patient and professional health-related education, public health, and health administration. The Office for the Advancement of Telehealth (OAT) promotes the use of telehealth technologies for healthcare delivery, education, and health information services. The office is part of the Office of Rural Health Policy, located within HRSA at the U.S. Department of Health and Human Services. HRSA’s mission is to assure quality health care for underserved, vulnerable, and special needs populations (HRSA, 2013a).
Blue Cross Blue Shield of Louisiana and Blue Cross Blue Shield of Massachusetts announced partnerships with American Well, a telehealth provider that also works with WellPoint. American Well will provide physician consultation to policyholders of those companies through iPads, iPhones, Android devices, and webcam-equipped PCs. Humana is planning a pilot telehealth initiative with Medicare Advantage patients (Golia, 2013).
CONCLUSION
Although hospitals admit 35 million individuals annually, the healthcare industry has recognized that outpatient services are a cost-effective method of providing quality health care and has therefore evolved into providing quality outpatient care. This type of service is the preferred method of receiving health care by the consumer. In 2013, there were over 900 million visits to doctor’s offices, which is the traditional method of ambulatory care (CDC, 2013b). However, as medicine has evolved and more procedures, such as surgeries, can be performed on an outpatient basis, different types of outpatient care have evolved. As discussed previously, there are more outpatient surgical centers, imaging centers, urgent/emergent care centers, and other services that used to be offered on an inpatient basis. There will continue to be an increase in outpatient services being offered. As a consumer, technology will only increase the quality and efficiency of your health care. Telemedicine will also become a more widely used model for health care because of the continued advances in technology. The implementation of the patient’s electronic health record nationwide will be the impetus for the development of more electronic healthcare services.