Optimization of Medical Supervision, Management, and Reimbursement of Contemporary Home Care

Optimization of Medical Supervision, Management, and Reimbursement of Contemporary Home Care

B. Spyropoulos (Technological Education Institute of Athens, Greece), M. Botsivaly (Technological Education Institute of Athens, Greece), A. Tzavaras (Technological Education Institute of Athens, Greece) and K. Koutsourakis (Technological Education Institute of Athens, Greece)
Copyright: © 2008 |Pages: 9
DOI: 10.4018/978-1-59904-889-5.ch128
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Adapting medical and managerial decision-making (Spyropoulos, 2006a) in the modern home care environment is a cardinal prerequisite, in order to ensure, first, an economically sustainable development of the aging population healthcare (Scarcelli, 2001); second, the rehabilitation services required for impaired persons; and finally, the psychosomatic support necessary in the developed countries, during the next decades. Thus, a strategic question emerges that is how home care will be medically supervised and financially reimbursed. The present study attempts to describe the present situation and the contemporary technological trends in home care; more specific, it is focused on a system developed by our team that intends first, to enable the optimal documentation of the provided home care, and second, to facilitate the acquisition of all relevant financial data, leading to a fair remuneration of the services offered.

Key Terms in this Chapter

Medical Classification: The method of transforming descriptions of medical diagnoses and procedures into universal Medical code numbers. These diagnosis and procedure codifications are used by health insurance companies for reimbursement purposes, they support statistical analysis of diseases and therapeutic actions, they are employed in knowledge-bases and medical decision support, and in a variety of other uses.

Continuity of Care Record (CCR): A health Record standard (ASTM E2369-05) specification that constitutes a patient health summary and contains the most relevant and timely core health information to be sent, usually in electronic form, from one care giver to another. It contains various sections such as patient demographics, insurance information, diagnosis and problem list, medications, allergies and care plan, representing a “snapshot” of a patient’s health data that can be useful or possibly lifesaving, if available at the time of clinical encounter. The CCR standard is expressed in the standard data interchange language known as XML and can potentially be created, read and interpreted by any EHR and EMR software applications. A CCR can also be exported in other formats, such as pdf, doc, and so on.

Clinical Document Architecture (CDA): An XML-based markup standard intended to specify the encoding, structure, and semantics of clinical documents for exchange. The CDA tries to ensure that the content will be human-readable and hence is required to content narrative text, yet still contain structure, and most importantly, allows for the use of codes to represent concepts.

American Society for Testing and Materials International (ASTM): An international voluntary standards organization established 1898 in the United States by Charles Benjamin Dudley. ASTM develops technical standards for materials, products, systems, and services, and maintains presently more than 12,000 standards that have been incorporated into or are referred to by many federal regulations.

Diagnosis Related Groups (DRGs): A system that classifies hospital cases into one of approximately 500–600 groups, which relate types of patients treated, to the hospital resources they consumed. It was first developed by Robert Barclay Fetter and John Devereaux Thompson at Yale University, in the slate 1970s. The DRGs are assigned by a “grouper” program based on ICD diagnoses, procedures, age, sex, and the presence of complications or comorbidities.

Health Level Seven Inc. (HL7): HL7 is a not-for-profit organization, established 1987, involved in the development of international healthcare standards, accredited by the American National Standards Institute (ANSI). HL7 is currently the selected standard for the interfacing of clinical data for most hospital information systems worldwide.

Clinical Care Classification (CCC): A categorization system that consists of interrelated terminologies—the CCC of Nursing Diagnoses and Outcomes and the CCC of Nursing Interventions and Actions—with both classified by 21 Care Components, that classify, and track care based on the six steps of the Nursing Process Standards of Care recommended (1998) by the American Nurses Association (ANA): assessment, diagnosis, outcome identification, planning, implementation and evaluation.

Homecare: Healthcare provided in the patient’s home by healthcare professionals or by family and friends. Homecare aims to enable people to remain at home rather than use institutional-based nursing care. Care workers visit patients in their own home to help them with daily tasks and supervision of treatment. Homecare is generally paid for by private health insurance, by public payers, or by the family’s or patients’ own resources.

Electronic Health Record (EHR): A personal medical record in digital format, typically accessed on a computer or over a network. An EHR almost includes information relating to the current and historical health, medical conditions, and medical tests of its subject. In addition, EHRs may contain data about medical referrals, medical treatments, medications and their application, demographic information, and other nonclinical administrative information.

Extensible Markup Language (XML): A general-purpose markup language designed to be reasonably human-legible, and therefore, abruptness was not considered essential in its structure. Its primary purpose is to facilitate the sharing of data across different information systems, particularly connected through the Internet, and to allow for diverse software to understand information formatted in this language.

International Statistical Classification of Diseases and Related Health Problems (ICD): The ICD is published by the World Health Organization (WHO), and provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. Every health condition can be assigned to a unique category and given a code, up to six characters long. Such categories can include a set of similar diseases. The ICD is used world-wide for morbidity and mortality statistics, reimbursement systems and automated decision support in medicine. This system is designed to promote international comparability in the collection, processing, classification, and presentation of these statistics. The ICD is the core classification of the WHO; it is revised periodically, and is currently in its tenth edition (ICD-10).

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