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An individual's ability to obtain appropriate health care services. Barriers to access can be financial, geographic, organizational and sociological. Efforts to improve access often focus on providing/improving health coverage.
As required by the Americans with Disabilities Act, removal of barriers that would hinder a person with a disability from entering, functioning, and working within a facility. Required restructuring of the facility cannot cause undue hardship for the employer or organization.
A process whereby a program of study or an institution is recognized by an external body as meeting certain predetermined standards. For facilities, accreditation standards are usually defined in terms of physical plant, governing body, administration, medical and other staff. Accreditation is often carried out by organizations created for the purpose of assuring the public of the quality achieved through an accredited institution or program. The state or federal governments can recognize accreditation in lieu of, or as the basis for licensure or other mandatory approvals. Public or private payment programs often require accreditation as a condition of payment for covered services. Accreditation may either be permanent or may be given for a specified period of time.
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Basic personal activities which include bathing, eating, dressing, mobility, transferring from bed to chair, and using the toilet. ADLs are used to measure how dependent a person may be on requiring assistance in performing any or all of these activities.
Care that is generally provided for a short period of time to treat a certain illness or condition. This type of care can include short-term hospital stays, doctor's visits, surgery, and X-rays. Medical treatment rendered to individuals whose illnesses or health problems are of a short-term or episodic nature. Acute care facilities are those hospitals that mainly serve persons with short-term health problems.
Date at which an individual was reported to have been admitted to a nursing home for which a Medicaid claim has been paid. Admission may occur before the beginning of a Medicaid-financed nursing home spell if a person entered the nursing home with other insurance coverage before Medicaid began covering the nursing facility care.
Adult Day programs provide clients with structured activity and, when needed, assistance with activities of daily living (ADLs). There are 2 types of adult day programs: 1) Adult Day Care (ADC), which offers personal care services, and 2) Adult Day Health (ADH), which offers personal care as well as skilled nursing and rehab services. Some day programs are designed specifically for persons needing memory care and support.
The process of discussing, determining and/or executing treatment directives and appointing a proxy decision maker.
(Also called advance directive.) Advance directives are legal documents that allow you to convey your decisions about end-of-life care ahead of time. They provide a way for you to communicate your wishes to family, friends and health care professionals, and to avoid confusion later on.
A living will tells how you feel about care intended to sustain life. You can accept or refuse medical care. There are many issues to address, including The use of dialysis and breathing machines; If you want to be resuscitated if breathing or heartbeat stops; Tube feeding; Organ or tissue donation.
A durable power of attorney for health care is a document that names your health care proxy. Your proxy is someone you trust to make health decisions if you are unable to do so.
Specially trained and licensed health workers other than physicians, dentists, optometrists, chiropractors, podiatrists, and nurses. The term has no constant or agreed-upon detailed meaning; it is sometimes used synonymously with paramedical personnel, sometimes meaning all health workers who perform tasks that otherwise must be performed by a physician, and at other times referring to health workers who do not usually engage in independent practice.
A progressive, irreversible disease characterized by degeneration of the brain cells and severe loss of memory, causing the individual to become dysfunctional and dependent upon others for basic living needs.
All types of health services which are provided on an outpatient basis, in contrast to services provided in the home or to persons who are inpatients. While many inpatients may be ambulatory, the term ambulatory care usually implies that the patient must travel to a location to receive services which do not require an overnight stay.
An individual must meet one of the following three tests: have a physical or mental impairment that substantially limits one or more of the major life activities of such individual; have a record of such an impairment; or be regarded as having an impairment. (Same as Section 504 of the Rehabilitation Act of 1973 and the Fair Housing Amendments of 1988.)
Supplemental services, including laboratory, radiology, physical therapy, and inhalation therapy, that are provided in conjunction with medical or hospital care.
A local (city or county) agency, funded under the federal Older Americans Act, that plans and coordinates various social and health service programs for persons 60 years of age or more. The network of AAA offices consists of more than 600 approved agencies.
An organization or organized system of health and educational institutions whose purpose is to improve the supply, distribution, quality, use, and efficiency of health care personnel in specific medically underserved areas. An AHEC's objectives are to educate and train the health personnel specifically needed by the underserved areas and to decentralize health workforce education, thereby increasing supply and linking the health and educational institutions in scarcity areas.
ALCs and PCHs provide services to residents who need assistance with personal care, medication management, and/or home management but do not require skilled health care. PCHs range in size from 2 beds in a private home to 100+ apartments. ALCs must have at least 25 apartments. Their services are similar, but eligibility requirements and payment options differ somewhat.
Tools that enable individuals with disabilities to perform essential job functions, e.g., telephone headsets, adapted computer keyboards, enhanced computer monitors.
An umbrella term that includes mental health and substance abuse, and frequently is used to distinguish from "physical" health. Health care services provided for depression or alcoholism would be considered behavioral health care, while setting a broken leg would be physical health.
An individual who receives benefits from or is covered by an insurance policy or other health care financing program.
The date on which benefit payments began during the reporting period.
Status granted a medical specialist who completes a required course of training and experience (residency) and passes an examination in his/her specialty. Individuals who have met all requirements except examination are referred to as "board eligible".
An individual's ability to understand the significant benefits, risks, and alternatives to proposed health care and to make and communicate a health care decision. The term is frequently used interchangeably with competency but is not the same. Competency is a legal status imposed by the court.
A method of payment for health services in which the provider is paid a fixed amount for each patient without regard to the actual number or nature of services provided. Capitation payments are characteristic of health maintenance organizations (HMOs). Also, a method of public support of health professional schools in which eligible schools receive a fixed grant for each student enrolled.
A group of treatments used when someone's heart and/or breathing stops. CPR is used in an attempt to restart the heart and breathing. It usually consists of mouth-to-mouth breathing and pressing on the chest to cause blood to circulate. Electric shock and drugs also are used to restart or control the rhythm of the heart.
A Care Plan is a written document which outlines the types and frequency of the long-term care services that a consumer receives. It may include treatment goals for him or her for a specified time period.
Person who provides support and assistance with various activities to a family member, friend, or neighbor. A caregiver may provide emotional or financial support, as well as hands-on help with different tasks. Caregivers can use the formal and informal supports that are available. Caregiving may also be done from long distance.
An unlicensed assistant who provides direct health related care to patients or residents, a proxy caregiver performing health maintenance activities providing care under the direction and orders of a licensed health care provider.
Offers a single point of entry to the aging services network. Care/case managers assess clients' needs, create service plans, and coordinate and monitor services; they may operate privately or may be employed by social service agencies or public programs. Typically case managers are nurses or social workers.
A set of actions designed to ensure the coordination and continuity of health care as individuals transfer between different locations or different levels of care within the same location. Representative locations include (but are not limited to) hospitals, sub-acute and post-acute nursing facilities, the individual’s home, primary and specialty care offices, and long-term care/retirement communities. Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well-trained in chronic care and have current information about the patient's goals, preferences, and clinical status. It includes logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition.
Health insurance that provides protection against the high cost of treating severe or lengthy illnesses or disability. Generally such policies cover all, or a specified percentage of, medical expenses above an amount that is the responsibility of another insurance policy up to a maximum limit of liability.
Persons whose Medicaid eligibility is based on their family, age or disability status. Persons not falling into these categories cannot qualify, no matter how low their income. The Medicaid statute defines over 50 distinct population groups as potentially eligible, including those for which coverage is mandatory in all states and those that may be covered at a state's option. The scope of covered services that states provide to the categorically needy is much broader than the minimum scope of services for the other, optional groups receiving Medicaid benefits.
A certificate issued by a government body to a health care provider who is proposing to construct, modify, or expand facilities, or to offer new or different types of health services. CON is intended to prevent duplication of services and over-bedding. The certificate signifies that the change has been approved.
The process by which a governmental or non-governmental agency or association evaluates and recognizes an individual, institution, or educational program as meeting predetermined standards. One so recognized is said to be "certified." It is essentially synonymous with accreditation, except that certification is usually applied to individuals, and accreditation to institutions. Certification programs are generally non-governmental and do not exclude the uncertified from practice as do licensure programs.
A certified nursing assistant has completed required state training and competency testing in the skills required to work as a CNA.
Help with chores such as home repairs, yard work, and heavy housecleaning.
Care and treatment given to individuals whose health problems are of a long-term and continuing nature. Rehabilitation facilities, nursing homes, and mental hospitals may be considered chronic care facilities.
A disease that has one or more of the following characteristics: is permanent; leaves residual disability; is caused by nonreversible pathological alternation; requires special training of the patient for rehabilitation; or may be expected to require a long period of supervision, observation, or care.
Long-term or permanent illness (e.g., diabetes, arthritis) which often results in some type of disability and which may require a person to seek help with various activities.
A patient has been certified by a licensed health care practitioner as: being unable to perform without substantial assistance from another person, at least two ADLs for a period that is expected to last at least 90 consecutive days due to a loss of functional capacity; or requiring substantial supervision to protect themselves from threats to health and safety due to a severe cognitive impairment.
See TRICARE. A Department of Defense program supporting private sector care for military dependents.
A program for the Handicapped (PFTH). Disability for military dependents is based on the strength and duration of a physical or mental handicap. The physical handicap must be of such severity as to preclude the individual from performing basic activities of daily living at a level expected of unimpaired individuals of the same age group. The handicap must also be expected to result in death or to have lasted or be expected to last for at least 12 months. For a mental handicap, the applicant must be medically determined to be moderately or severely retarded.
Indicates whether or not an insured with a Partnership policy is in claim status during the reporting period.
A facility, or part of one, devoted to diagnosis and treatment of outpatients. "Clinic" is irregularly defined. It may either include or exclude physicians' offices, may be limited to describing facilities that serve poor or public patients, and may be limited to facilities in which graduate or undergraduate medical education is done.
A diagnosis (e.g., cerebrovascular hemorrhage) or a patient state that may be associated with more than one diagnosis (such as paraplegia) or that may be as yet undiagnosed (such as low back pain).
Services provided to patients (items of history taking, physical examination, preventative care, tests, procedures, drugs, advice) or information on clinical condition or on patient state used as a patient outcome.
The specified portion (dollar amount or percentage) that Medicare, health insurance, or a service program may require a person to pay toward his or her medical bills or services.
Co-Insurance is a cost-sharing requirement under a health insurance policy. It provides that the insured party will assume a portion or percentage of the costs of covered services. The health insurance policy provides that the insurer will reimburse a specified percentage of all, or certain specified, covered medical expenses in excess of any deductible amounts payable by the insured. The insured is then liable for the remainder of the costs until their maximum liability is reached.
Condition that exists at the same time as the primary condition in the same patient (e.g., hypertension is a co-morbidity of many conditions such as diabetes, ischemic heart disease, end-stage renal disease, etc.).
A fixed amount of money paid by a health plan enrollee (beneficiary) at the time of service. For example, the enrollee may pay a $10 "co-pay" at every physician office visit, and $5 for each drug prescription filled. The health plan pays the remainder of the charge directly to the provider. This is a method of cost-sharing between the enrollee and the plan, and serves as an incentive for the enrollee to use healthcare resources wisely. An enrollee might be offered a lower price benefit package in return for a higher co-payment.
Deterioration or loss of intellectual capacity which requires continual supervision to protect the individual or others, as measured by clinical evidence and standardized tests that reliably measure impairment in the area of short or long-term memory, orientation as to person, place and time, or deductive or abstract reasoning. Such loss in intellectual capacity can result from Alzheimer's disease or similar forms of senility or Irreversible Dementia.
A Medicaid waiver program where social workers and registered nurses work as a team to coordinate a range of personal, household, and health-related home and community-based services for clients in their homes
(Also called neighborhood health center.) An ambulatory health care program usually serving a catchment area which has scarce or nonexistent health services or a population with special health needs. These centers attempt to coordinate federal, state, and local resources in a single organization capable of delivering both health and related social services to a defined population. While such a center may not directly provide all types of health care, it usually takes responsibility to arrange all medical services needed by its patient population.
An entity that provides comprehensive mental health services (principally ambulatory), primarily to individuals residing or employed in a defined catchment area.
A person who purchases or receives goods or services for personal needs or use and not for resale.
CCRCs provide 3 levels of accommodations: independent living, personal care/assisted living, and skilled nursing/rehab. Services vary by level of accommodation. Most CCRCs require new residents to pay a one-time entrance fee prior to admission. Entrance fee refund policies vary. All CCRCs require payment of monthly or daily service fees.
Increase to an individual's salary or other benefit payment, usually after the first year of payments. May be a flat percentage (e.g., 3%) or tied to changes in inflation. For example, in some states, workers' compensation income replacement benefits or long-term disability benefits include annual COLAs.
Health care services covered by an insurance plan.
A rural hospital designation established by the Medicare Rural Hospital Flexibility Program (MRHFP) enacted as part of the 1997 Balanced Budget Act. Rural hospitals meeting criteria established by their state may apply for critical access hospital status. Designated hospitals are reimbursed based on cost (rather than prospective payment), must comply with federal and state regulations for CAHs, and are exempt from certain hospital staffing requirements.
The culture change movement is dedicated to transforming the old institutional, hospital-like environments and models of care into organizations, communities, and environments that focus on “person-centered,” “resident-directed,” or “patient-directed” care ~ where the person comes first. The goal is to de-institutionalize long-term care and transform the environments into “home.” Regardless of the setting or the services provided, it is a focus on quality care that provides quality of life.
Care that does not require specialized training or services.
Term which describes a group of diseases (including Alzheimer's Disease) which are characterized by memory loss and other declines in mental functioning.
A disability which originates before age 18, can be expected to continue indefinitely, and constitutes a substantial handicap to the person's ability to function normally.
A severe, chronic disability that is attributable to a mental or physical impairment or combination of mental and physical impairments; is manifested before the person attains age 22; is likely to continue indefinitely; results in substantial functional limitations in three or more of the following areas of major life activity: self-care, receptive and expressive language, learning, mobility, self-direction, capacity of independent living, economic self-sufficiency; and reflects the person's needs for a combination and sequence of special, interdisciplinary, or generic care treatments of services which are of lifelong or extended duration and are individually planned and coordinated.
[Also see All Patient Diagnosis-Related Group (APDRG)] A classification system which uses diagnosis information to establish hospital payments under Medicare. This system groups patient needs into 467 categories, based upon the coding system of the International Classification of Disease, Ninth Revision-Clinical Modification (ICD-9-CM).
Groupings of diagnostic categories drawn from the International Classification of Diseases and modified by the presence of a surgical procedure, patient age, presence or absence of significant co-morbidities or complications, and other relevant criteria. DRGs are the case-mix measure used in Medicare's prospective payment system.
Any activities by a health professional involving direct interaction, treatment, administration of medications, or other therapy or involvement with a patient.
The limitation of normal physical, mental, social activity of an individual. There are varying types (functional, occupational, learning), degrees (partial, total), and durations (temporary, permanent) of disability. Benefits are often available only for specific disabilities, such as total and permanent (the requirement for Social Security and Medicare).
The release of a patient from a provider's care, usually referring to the date at which a patient checks out of a hospital.
A discharge planner, often a social worker, is a core member of a hospital patient's care-facilitation team. Working with the attending physician, specialists and bedside nurses, the discharge planner helps to coordinate the patient's transition to life after the hospital, often working with the patient's family, nursing homes, medical-equipment providers and insurance companies to smoothly facilitate a patient's move to the next level of care.
Disease management is a system of coordinated health care interventions and communications for populations with conditions (e.g., patients with asthma or diabetes) in which patient self-care efforts are significant. Disease management could include team-based care where physicians and/or other health professionals participate in the delivery and management of care. It also includes the appropriate use of pharmaceuticals.
(Also called a DNR order, a No CPR order, a DNAR order (do not attempt resuscitation), and an AND order (allow natural death).) [See also Physician Orders for Life-Sustaining Treatment (POLST).] A physician's order written in a patient's medical record indicating that health care providers should not attempt CPR in the event of cardiac or respiratory arrest. In some regions, this order may be transferable between medical venues.
A person who is eligible for two health insurance plans, often referring to a Medicare beneficiary who also qualifies for Medicaid benefits.
(Also called Home Medical Equipment) Equipment such as hospital beds, wheelchairs, ventilator, oxygen system, home dialysis system, and prosthetics used at home. DME may be covered by Medicaid and in part by Medicare or private insurance. DME may also be prescribed by a physician for a patient's use for an extended period of time.
(See Advanced Directive for Health Care) A durable power of attorney for health care is a document that names your health care proxy. Your proxy is someone you trust to make health decisions if you are unable to do so.
Services utilized in responding to the perceived individual need for immediate treatment for medical, physiological, or psychological illness or injury.
A federal act, passed in 1974, that established new standards and reporting/disclosure requirements for employer-funded pension and health benefit programs.
By law states are required to recover funds from certain deceased Medicaid recipients' estates up to the amount spent by the state for all Medicaid services (e.g., nursing facility, home and community-based services, hospital, and prescription costs).
A 1993 federal law requiring employers with more than 50 employees to provide eligible workers up to 12 weeks of unpaid leave for birth, adoptions, foster care placement, and illnesses of employees and their families.
The way traditional Medicare and health insurance work. Medical providers bill for whatever service they provide. Medicare and/or traditional insurance pay their share, and the patient pays the balance through co-payments and deductibles.
A payment mechanism in which payment is made for each utilized service. FFS services exclude services provided under capitated arrangements.
Organization or company in which profits are distributed to shareholders or private owners.
Physician who is certified in the care of older people.
Medical specialty focusing on treatment of health problems of the elderly.
Study of the biological, psychological and social processes of aging.
A judicially appointed guardian or conservator having authority to make a health care decision for an individual.
As defined by Section 504 of the Rehabilitation Act of 1973, any person who has a physical or mental impairment which substantially limits one or more major life activity, has a record of such impairment, or is regarded as having such an impairment.
Those individuals diagnosed as having a handicapping condition in accordance with the following definitions: mentally retarded; seriously emotionally disturbed; specific learning disability; hearing, speech, or sight impaired; physical or health handicapped. Persons should not be counted as handicapped unless they have been clinically diagnosed as having these conditions. Use one primary diagnosis for multiply handicapped children.
Financial protection against the medical care costs arising from disease or accidental bodily injury. Such insurance usually covers all or part of the medical costs of treating the disease or injury. Insurance may be obtained on either an individual or a group basis.
Federal health insurance legislation passed in 1996, which sets standards for access, portability, and renewability that apply to group coverage--both fully insured and self-funded--as well as to individual coverage. HIPAA allows under specified conditions, for long-term care insurance policies to be qualified for certain tax benefits under Section 7702(b) of the Internal Revenue Code.
Managed care organization that offers a range of health services to its members for a set rate, but which requires its members to use health care professionals who are part of its network of providers. (See also Medicare HMOs.)
Medicaid waiver programs provide supportive services to individuals who are eligible for nursing home placement but want to remain in their homes (private homes, HUD-subsidized communities, non-subsidized retirement communities, personal care homes, assisted living communities, and continuing care retirement communities). In Georgia, there are two main waiver programs for elders: the Community Care Services Program (CCSP) and Service Options Using Resources in Community Environments (SOURCE).
HCBS organizations provide a range of personal, household, and health-related services to help clients age in place wherever they choose to live. Services are delivered in the client’s home (such as home care, home-delivered meals, home hospice, etc.) and/or the organization’s own facility/senior center (such as adult day care, adult day health, and congregate meals, etc.).
HOME CARE provides one or more of the following categories of services in a client’s home: companion/sitting, personal care, and skilled nursing. Home care staff typically spend from 4 to 24 hours in a client’s home. However, shorter visits are offered for home care services in some retirement housing communities.
HOME HEALTH CARE provides short-term, intermittent (not daily) skilled health care services to patients in their homes, typically for up to 60 days, and often following a hospital discharge. Skilled nursing is provided by RNs and LPNs, and rehabilitation services (such as physical therapy and speech therapy) are provided by licensed therapists. A physician’s order is required for all services.
ADULT DAY PROGRAMS provide clients with structured activity and, when needed, assistance with activities of daily living (ADLs). There are 2 types of adult day programs: 1) Adult Day Care (ADC), which offers personal care services, and 2) Adult Day Health (ADH), which offers personal care as well as skilled nursing and rehab services. Some day programs are designed specifically for persons needing memory care and support.
HEALTH EDUCATION & WELLNESS PROGRAMS maintain people's health through direct teaching, counseling and similar services.
CAREGIVER SUPPORT OR TRAINING instructs family caregivers in techniques that improve their ability to assist an older relative or spouse, and educates them about formal and informal supports that are available.
HOSPICE CARE provides end-of-life care to patients with a terminal illness and a life expectancy of less than 6 months. Because most people prefer to stay at home, services are usually provided in the home setting as opposed to an in-patient facility. Services are provided by an inter-disciplinary clinical team including nurses, certified nursing assistants (CNAs), social workers, volunteers, bereavement counselors, chaplains, and medical directors.
RESPITE CARE allows family caregivers to have a brief rest by providing temporary, overnight care for the ill or disabled for a few days or weeks.
HOME-DELIVERED MEALS, often called Meals-on-Wheels, bring nutritionally balanced meals to those unable to prepare their own food.
CONGREGATE DINING PROGRAMS offer low-cost, nutritious meals served in group settings.
TELEPHONE REASSURANCE provides regular telephone contact and a sense of security for people living at home.
TRANSPORTATION SERVICES help individuals keep appointments and enjoy recreational opportunities.
SENIOR CENTERS offer individuals a place to visit daily for a variety of social and recreational services to reduce isolation and keep life interesting and satisfying.
INFORMATION AND REFERRAL PROGRAMS help identify and locate services in the community.
Home Care provides one or more of the following categories of services in a client’s home: companion/sitting, personal care, and skilled nursing. Home care staff typically spend from 4 to 24 hours in a client’s home. However, shorter visits are offered for home care services in some retirement housing communities.
Home Health Care provides short-term, intermittent (not daily) skilled health care services to patients in their homes, typically for up to 60 days, and often following a hospital discharge. Skilled nursing is provided by RNs and LPNs, and rehabilitation services (such as physical therapy and speech therapy) are provided by licensed therapists. A physician’s order is required for all services.
A public or private organization that provides home health services supervised by a licensed health professional in the patient's home either directly or through arrangements with other organizations.
A person who, under the supervision of a home health or social service agency, assists elderly, ill or disabled person with household chores, bathing, personal care, and other daily living needs. Social service agency personnel are sometimes called personal care aides.
Includes a wide range of health-related services such as assistance with medications, wound care, intravenous (IV) therapy, and help with basic needs such as bathing, dressing, mobility, etc., which are delivered at a person's home.
The maximum amount which the policy or certificate will pay for care received at home (or for home and other community care benefits). If the benefit is paid as weekly or monthly, the daily amount should be derived by whatever convention is most appropriate for the carrier to use. The data should be the current amount on the policy in order to account both for any voluntary increases in coverage the insured has elected or any automatic coverage increases as a result of inflation protection.
(Also called Durable Medical Equipment) Equipment such as hospital beds, wheelchairs, and prosthetics used at home. Home Medical Equipment may be covered by Medicaid and in part by Medicare or private insurance.
One of the requirements to qualify for Medicare home health care. Means that someone is generally unable to leave the house, and if they do leave home, it is only for a short time (e.g., for a medical appointment) and requires much effort.
In-home help with meal preparation, shopping, light housekeeping, money management, personal hygiene and grooming, and laundry.
Hospice organizations provide end-of-life care to patients with a terminal illness and a life expectancy of less than 6 months. Because most people prefer to stay at home, services are usually provided in the home setting as opposed to an in-patient facility. Services are provided by an inter-disciplinary clinical team including nurses, certified nursing assistants (CNAs), social workers, volunteers, bereavement counselors, chaplains, and medical directors. In-patient hospice care can be delivered in an in-patient hospice facility and in other settings such as a skilled nursing home.
An institution whose primary function is to provide inpatient diagnostic and therapeutic services for a variety of medical conditions, both surgical and nonsurgical.
There are 3 categories of HUD-subsidized housing: 1) HUD Elderly Housing (EH), 2) HUD Public Housing (PH), and 3) HUD Low-Income Housing Tax Credit Communities (LIHTC). Services are similar across types, but eligibility requirements and payment options differ somewhat. Also, some HUD-subsidized housing communities provide dedicated personal care/assisted living apartments.
Any loss or abnormality of psychological, physiological, or anatomical function.
All non-subsidized retirement communities offer independent living accommodations. Some also offer personal care/assisted living, and skilled nursing/rehab services. These communities are also known as Senior Living Communities or, in a few cases, Continuing Care Retirement Communities (CCRCs).
Health services provided to the poor or those unable to pay. Since many indigent patients are not eligible for federal or state programs, the costs which are covered by Medicaid are generally recorded separately from indigent care costs.
A person who has been admitted at least overnight to a hospital or other health facility (which is therefore responsible for his or her room and board) for the purpose of receiving diagnostic treatment or other health services.
Health services delivered on an inpatient basis in hospitals, nursing homes, or other inpatient institutions. The term may also refer to services delivered on an outpatient basis by departments or other organizational units of, or sponsored by, such institutions.
Nursing facility services, services provided in ICFs/MR, mental hospital services for people over age 65, and inpatient psychiatric facility services for individuals under age 21.
Household/independent living tasks which include using the telephone, taking medications, money management, housework, meal preparation, laundry, and grocery shopping.
Occasional nursing and rehabilitative care ordered by a doctor and performed or supervised by skilled medical personnel.
A nursing home, recognized under the Medicaid program, which provides health-related care and services to individuals who do not require acute or skilled nursing care, but who, because of their mental or physical condition, require care and services above the level of room and board available only through facility placement. Specific requirements for ICF's vary by state. Institutions for care of the mentally retarded or people with related conditions (ICF/MR) are also included. The distinction between "health-related care and services" and "room and board" is important since ICF's are subject to different regulations and coverage requirements than institutions which do not provide health-related care and services.
An ICF which cares specifically for the mentally retarded.
Amount of assistance required by consumers which may determine their eligibility for programs and services. Levels include: protective, intermediate, and skilled.
Permission granted to an individual or organization by a competent authority, usually public, to a engage lawfully in a practice, occupation, or activity.
Medical procedures that replace or support an essential bodily function. Life-sustaining treatments include CPR, mechanical ventilation, artificial nutrition and hydration, dialysis, and certain other treatments.
(See Advanced Directive for Health Care.) A living will tells how you feel about care intended to sustain life. You can accept or refuse medical care. There are many issues to address, including The use of dialysis and breathing machines; If you want to be resuscitated if breathing or heartbeat stops; Tube feeding; Organ or tissue donation.
Range of medical and/or social services designed to help people who have disabilities or chronic care needs. Services may be short-term or long-term and may be provided in a person's home, in the community, or in residential facilities (e.g., nursing homes or Assisted Living\Personal Care).
Insurance policies which pay for long-term care services that Medicare and Medigap policies do not cover. Policies vary in terms of what they will cover, and may be expensive. Coverage may be denied based on health status or age. Consumers who qualify can pay out of pocket for long-term care insurance. Benefits vary widely among policies, but most have some type of coverage for long-term nursing home care, home care, personal care/assisted living, adult day care, and adult day health.
An individual designated by a state or a substate unit responsible for investigating and resolving complaints made by or for older people in long-term care facilities. Also responsible for monitoring federal and state policies that relate to long-term care facilities, for providing information to the public about the problems of older people in facilities, and for training volunteers to help in the ombudsman program. The long-term care ombudsman program is authorized by Title III of the Older Americans Act.
Method of organizing and financing health care services which emphasizes cost-effectiveness and coordination of care. Managed care organizations (including HMOs, PPOs, and PSOs) receive a fixed amount of money per client/member per month (called a capitation), no matter how much care a member needs during that month.
Payment mechanism used to manage health care, including services provided by health maintenance organizations or Programs of All-Inclusive Care for the Elderly, prepaid health plans, and primary care case management plans.
Medicaid is a health insurance program that uses federal and state tax dollars to provide long-term care and services to low income individuals who are aged, blind and/or disabled. Applications are made in several ways, but most often individuals go to the Department and Family and Children’s Services office in the county where they will to receive services.
Medicaid waiver programs provide supportive services to individuals who are eligible for nursing home placement but want to remain in their homes (private homes, HUD communities, retirement communities, personal care homes, assisted living communities, and continuing care retirement communities). In Georgia, there are two Medicaid waiver programs: Community Care Services Program (CCSP) and Service Options Using Resources in Community Environments (SOURCE).
Services or supplies which are appropriate and consistent with the diagnosis in accord with accepted standards of community practice and are not considered experimental. They also cannot be omitted without adversely affecting the individual's condition or the quality of medical care.
People who cannot afford needed health care because of insufficient income and/or lack of adequate health insurance.
Medicare is a federal health insurance program for persons over the age of 65. There are 4 categories of coverage:
Medicare Part A: Pays toward hospital room and board, home health care, skilled nursing home care and rehab in a skilled nursing home, and hospice care.
Medicare Part B: Pays toward doctors’ fees and other outpatient services.
Medicare Part C: Allows people to choose a Medicare Advantage Plan, thus opting out of traditional Medicare Parts A and B.
Medicare Part D: Pays toward prescription drug coverage.
Under Medicare HMOs (health maintenance organizations), members pay their regular monthly premiums to Medicare, while Medicare pays the HMO a fixed sum of money each month to provide Medicare benefits (e.g., hospitalization, doctor's visits, and more). Medicare HMOs may provide extra benefits over and above regular Medicare benefits (such as prescription drug coverage, eyeglasses, and more). Members do not pay Medicare deductibles and co-payments; however, the HMO may require them to pay an additional monthly premium and co-payments for some services. If members use providers outside the HMO's network, they pay the entire bill themselves unless the plan has a point of service option.
(Also called Medigap.) Insurance supplement to Medicare that is designed to fill in the "gaps" left by Medicare (such as co-payments). May pay for some limited long-term care expenses, depending on the benefits package purchased.
(Also called Medicare Supplement Insurance.) Insurance supplement to Medicare that is designed to fill in the "gaps" left by Medicare (such as co-payments). May pay for some limited long-term care expenses, depending on the benefits package purchased.
The capacity in an individual to function effectively in society. Mental health is a concept influenced by biological, environmental, emotional, and cultural factors and is highly variable in definition, depending on time and place. It is often defined in practice as the absence of any identifiable or significant mental disorder and sometimes improperly used as a synonym for mental illness.
A deficiency in the ability to think, perceive, reason, or remember, which results in loss of the ability to take care of one's daily living needs.
Significantly subaverage general intellectual functioning (specifically an I.Q. below 70) existing concurrently with deficits in adaptive behavior manifested during the developmental period (age 0-21).
Money Follows the Person (MFP) is a rebalancing initiative that was made possible by an eleven-year grant to states from the Centers for Medicare and Medicaid Services (CMS). This grant is designed to help individuals who are institutionalized in nursing facilities and intermediate care facilities (ICF) for people with developmental disabilities return to their homes and communities.
The extent of illness, injury, or disability in a defined population. It is usually expressed in general or specific rates of incidence or prevalence.
Death. Used to describe the relation of deaths to the population in which they occur.
An ambulatory health care program usually serving a catchment area which has scarce or nonexistent health services or a population with special health needs. These centers attempt to coordinate federal, state, and local resources in a single organization capable of delivering both health and related social services to a defined population. While such a center may not directly provide all types of health care, it usually takes responsibility to arrange all medical services needed by its patient population.
An organization that reinvests all profits back into that organization.
An individual trained to care for the sick, aged, or injured. Can be defined as a professional qualified by education and authorized by law to practice nursing.
A registered nurse working in an expanded nursing role, usually with a focus on meeting primary health care needs. NPs conduct physical examinations, interpret laboratory results, select plans of treatment, identify medication requirements, and perform certain medical management activities for selected health conditions. Some NPs specialize in geriatric care.
Nursing homes offer two levels of care: long-term care and short-term rehab. Upon discharge from rehab, patients often need follow-up care in their homes. Prior to discharge, nursing home staff coordinate home- and community-based services delivered in the patient’s home, such as home health care, home care, medical equipment, etc.
The maximum amount which the policy or certificate will pay for care received in a nursing home. If the benefit is paid as weekly or monthly, the daily amount should be derived by whatever convention is most appropriate for the carrier to use. The data should be the current amount on the policy in order to account both for any voluntary increases in coverage the insured has elected or any automatic coverage increases as a result of inflation protection.
State and federal laws to protect each nursing home resident's civil, religious and human rights.
Designed to help patients improve their independence with activities of daily living through rehabilitation, exercises, and the use of assistive devices. Occupational Therapy may be covered in part by Medicare.
Federal legislation that specifically addresses the needs of older adults in the United States. It provides some funding for aging services (such as home-delivered meals, congregate meals, senior center, and employment programs). OAA creates the structure of federal, state, and local agencies that oversee aging services programs.
A representative of a public agency or a private nonprofit organization who investigates and resolves complaints made by or on behalf of older individuals who are residents of long-term care facilities.
A patient who is receiving ambulatory care at a hospital or other facility without being admitted to the facility. Usually, it does not mean people receiving services from a physician's office or other program which also does not provide inpatient care.
A comprehensive approach to treating serious illness that focuses on the physical, psychological, and spiritual needs of the patient. Its goal is to achieve the best quality of life available to the patient by relieving suffering, controlling pain and symptoms, and enabling the patient to achieve maximum functional capacity. Respect for the patient's culture, beliefs, and values is an essential component.
A vegetative state is a clinical condition of complete unawareness of the self and the environment accompanied by sleep-wake cycles with either complete or partial preservation of hypothalamic and brainstem autonomic functions. The PVS is a vegetative state present at one month after acute traumatic or non-traumatic brain injury, and present for at least one month in degenerative/metabolic disorders or developmental malformations. A PVS can be diagnosed on clinical grounds with a high degree of medical certainty in most adult and pediatric patients after careful, repeated neurologic examinations by a physician competent in neurologic function assessment and diagnosis. A PVS patient becomes permanently vegetative when the diagnosis of irreversibility can be established with a high degree of clinical certainty (i.e., when the chance of regaining consciousness is exceedingly rare).
PCHs and ALCs provide services to residents who need assistance with personal care, medication management, and/or home management but do not require skilled health care. PCHs range in size from 2 beds in a private home to 100+ apartments. ALCs must have at least 25 apartments. Their services are similar, but eligibility requirements and payment options differ somewhat.
Designed to restore/improve movement and strength in people whose mobility has been impaired by injury and disease. May include exercise, massage, water therapy, and assistive devices. May be covered in part by Medicare.
(Also known as a physician extender.) A specially trained and licensed or otherwise credentialed individual who performs tasks, which might otherwise be performed by a physician, under the direction of a supervising physician.
A health insurance benefits program in which subscribers can select between different delivery systems (i.e., HMO, PPO and fee-for-service) when in need of medical services, rather than making the selection between delivery systems at time of open enrollment at place of employment.
The Physician Orders for Scope of Treatment (POLST) Paradigm program is designed to improve the quality of care people receive at the end of life. It is based on effective communication of patient wishes, documentation of medical orders on a brightly colored form and a promise by health care professionals to honor these wishes.
A Physician Order guided by the patient’s medical condition and based upon personal preferences as expressed to the physician by the patient while in a competent condition, or in the patient’s advance directive, or by a representative of the patient acting with legal authority.
(Also called subacute care or transitional care.) Type of short-term care provided by many long-term care facilities and hospitals which may include rehabilitation services, specialized care for certain conditions (such as stroke and diabetes) and/or post-surgical care and other services associated with the transition between the hospital and home. Residents on these units often have been hospitalized recently and typically have more complicated medical needs. The goal of subacute care is to discharge residents to their homes or to a lower level of care.
A process under which admission to a health institution is reviewed in advance to determine need and appropriateness and to authorize a length of stay consistent with norms for the evaluation.
Illnesses or disability for which the insured was treated or advised within a stipulated time period before making application for a life or health insurance policy. A pre-existing condition can result in cancellation of the policy.
Managed care organization that operates in a similar manner to an HMO or Medicare HMO except that this type of plan has a larger provider network and does not require members to receive approval from their primary care physician before seeing a specialist. It is also possible to use doctors outside the network, although there may be a higher co-payment.
The periodic payment (e.g., monthly, quarterly) required to keep an insurance policy in force. The charge paid by a policyholder for insurance coverage.
Care which has the aim of preventing disease or its consequences. It includes health care programs aimed at warding off illnesses (e.g., immunizations), early detection of disease (e.g., Pap smears), and inhibiting further deterioration of the body (e.g., exercise or prophylactic surgery). Preventive medicine is also concerned with general prevention measures aimed at improving the healthfulness of the environment.
Basic or general health care focused on the point at which a patient ideally first seeks assistance from the medical care system.
Services, except those for mental health or substance abuse treatment, provided by registered nurses or licensed practical nurses under direction of a physician to recipients in their own homes, hospitals, or nursing facilities as specified by the state.
Amounts a nursing home liability insurer is legally obligated to pay as damages and associated claims and defense expenses to a plaintiff due to a negligent act, error or omission in a nursing home provider's rendering or failure to render professional services.
A managed care plan that coordinates Medicare and Medicaid acute care and long-term care for dual eligible enrollees (those age 55 and older, living in a PACE area, and otherwise eligible for nursing home care). A capitated payment mechanism is used for PACE plan enrollees. (PACE is not currently used in Georgia: see SOURCE.)
Individual or organization that provides health care or long-term care services (e.g., doctors, hospital, physical therapists, home health aides, and more).
Managed care organization that is similar to an HMO or Medicare HMO except that the organization is owned by the providers in that plan and these providers share the financial risk assumed by the organization.
Substitute decision maker.
An optional Medicaid service that can include (depending on state definitions) community support programs, school-based services, crisis intervention services, and outpatient psychotherapy services.
The science dealing with the protection and improvement of community health by organized community effort.
Civil litigation means monetary compensation awarded by a judge or jury which exceeds the losses suffered by the injured party in order to punish the defendant.
The specific conditions for which the individual qualifies as chronically ill. This could include dependency in the required number of ADLs, cognitive impairment or both.
Quality of Care can be defined as a measure of the degree to which delivered health services meet established professional standards and judgments of value to the consumer.
A nurse who has graduated from a formal program of nursing education and has been licensed by an appropriate state authority. RNs are the most highly educated of nurses with the widest scope of responsibility, including all aspects of nursing care. RNs can be graduated from one of three educational programs: two-year associate degree program, three-year hospital diploma program, or four-year baccalaureate program.
The combined and coordinated use of medical, social, educational, and vocational measures for training or retaining individuals disabled by disease or injury to the highest possible level of functional ability. Several different types of rehabilitation are distinguished: vocational, social, psychological, medical, and educational.
Services designed to improve/restore a person's functioning; includes physical therapy, occupational therapy, and/or speech therapy. Rehabilitation Services may be provided at home or in long-term care facilities and may be covered in part by Medicare.
The process by which health care providers receive payment for their services. Because of the nature of the health care environment, providers are often reimbursed by third parties who insure and represent patients.
Under a policy design with a single pool of dollars as the Lifetime Maximum, the total dollar amount of benefits remaining available to the insured in the Lifetime Maximum at the end of the reporting period.
The diagnostic evaluation, management, and treatment of the care of patients with deficiencies and abnormalities in the cardiopulmonary (heart-lung) system.
Service in which trained professionals or volunteers come into the home to provide short-term care (from a few hours to a few days) for an older person to allow caregivers some time away from their caregiving role.
Enrollee who receives limited Medicaid coverage, including unqualified aliens only eligible for emergency hospital benefits, duals receiving only Medicare cost-sharing benefits, and people eligible for only family-planning services.
All non-subsidized retirement communities offer independent living accommodations. Some also offer personal care/assisted living and skilled nursing/rehab services. These communities are also known as Senior Living Communities, Independent Living Retirement Communities or, in a few cases, Continuing Care Retirement Communities (CCRCs).
The use of quick procedures to differentiate apparently well persons who have a disease or a high risk of disease from those who probably do not have the disease.
The generalized characterization of progressive decline in mental functioning as a condition of the aging process. Within geriatric medicine, this term has limited meaning and is often substituted for the diagnosis of senile dementia and/or senile psychosis.
All non-subsidized retirement communities offer independent living accommodations for seniors. Some also offer personal care/assisted living and skilled nursing/rehab services. These communities are also known as Independent Living Retirement Communities or, in a few cases, Continuing Care Retirement Communities (CCRCs).
Provides a variety of on-site programs for older adults including recreation, socialization, congregate meals, and some health services. Senior centers are usually a good source of information about area programs and services.
A Service Plan is a written document which outlines the types and frequency of the long-term care services that a consumer receives. It may include treatment goals for him or her for a specified time period.
A risk prediction system to correlate the "seriousness" of a disease in a particular patient with the statistically "expected" outcome (e.g., mortality, morbidity, efficiency of care).
"Higher level" of care (such as injections, catheterizations, and dressing changes) provided by trained medical professionals, including nurses, doctors, and physical therapist.
Daily nursing and rehabilitative care, prescribed by a physician, that can be performed only by or under the supervision of skilled medical personnel.
Skilled Nursing Facilities (also called Skilled Nursing Homes/Rehab) offer two levels of care: long-term care and short-term rehab. Upon discharge from rehab, patients often need follow-up care in their homes. Prior to discharge, nursing home staff coordinate home- and community-based services delivered in the patient’s home, such as home health care, home care, medical equipment, etc.
Skilled Nursing Homes/Rehab (also called Skilled Nursing Facilities) offer two levels of care: long-term care and short-term rehab. Upon discharge from rehab, patients often need follow-up care in their homes. Prior to discharge, nursing home staff coordinate home- and community-based services delivered in the patient’s home, such as home health care, home care, medical equipment, etc.
A system of federally provided payments to eligible workers (and, in some cases, their families) when they are unable to continue working because of a disability. Benefits begin with the sixth full month of disability and continue until the individual is capable of substantial gainful activity.
An individual must have an inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than 12 months. To meet this definition, an individual's impairment or combination of impairments must be so severe that he or she is unable to do past work, but cannot, considering age, education, and work experience, engage in any other kind of substantial gainful activity which exists in the national economy. SSDI benefits are also paid to dependents (age 18-64) of retired, deceased or disabled workers provided they were disabled in childhood, and widows/widowers aged 50 or over who were married to SSDI beneficiaries. There are different rules for determining disability for those who are statutorily blind (i.e. with central visual, acuity of 20/200 or less in the better eye with the use of correcting lens), widow/widowers, and surviving divorced wives.
A managed system of health and long-term care services geared toward an elderly client population. Under this model, a single provider entity assumes responsibility for a full range of acute inpatient, ambulatory, rehabilitative, extended home health and personal care services under a fixed budget which is determined prospectively. Elderly people who reside in the target service area are voluntarily enrolled. Once enrolled, individuals are obligated to receive all SHMO covered services through SHMO providers similar to the operation of a medical model health maintenance organization (HMO).
Social Services Block Grant services are grants given to states under the Social Security Act which fund limited amounts of social services for people of all ages (including some in-home services, abuse prevention services, and more).
SOURCE is a Medicaid-managed care program for coordinating a range of personal, household, and health-related services for clients in their homes. Services have physician oversight, and clients must agree to use a SOURCE primary care physician.
Long-term care facility units with services specifically for persons with Alzheimer's Disease, dementia, head injuries, or other disorders.
Designed to help restore speech through exercises. Speech Therapy may be covered by Medicare.
A series of months during which a person received Medicaid-covered nursing home services for at least one day of each month and received no such services during the month preceding and following the series.
Medicaid financial eligibility requirements are strict and may require beneficiaries to spend down/use up assets or income until they reach the eligibility level.
Federal regulations preserve some income and assets for the spouse of a nursing home resident whose stay is covered by Medicaid.
Authorized by the Older Americans Act. Each state has an office at the state level which administers the plan for service to the aged and coordinates programs for the aged with other state offices.
A program of support for low-income aged, blind and disabled persons, established by Title XVI of the Social Security Act. SSI replaced state welfare programs for the aged, blind and disabled in 1972, with a federally administered program, paying a monthly basic benefit nationwide of $284.30 for an individual and $426.40 for a couple in 1983. States may supplement this basic benefit amount.
Individuals can qualify as disabled or blind. For disability, an individual must have an inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than 12 months. For blindness, an individual must be statutorily blind, that is, having central visual, acuity of 20/200 or less in the better eye with the use of correcting lens. Adults: To meet this definition, an individual's impairment or combination of impairments must be so severe that he or she is unable to do past work, but cannot, considering age, education, and work experience, engage in any other kind of substantial gainful activity which exists in the national economy. Children: A child under age 18 will be considered disabled for purposes of eligibility if he suffers from any medically determinable physical or mental impairment of "comparable severity" to that which would make an adult disabled.
Groups of people who share a common bond (e.g., caregivers) who come together on a regular basis to share problems and experiences. Support Groups may be sponsored by social service agencies, senior centers, religious organizations, as well as organizations such as the Alzheimer's Association.
(Also called proxy by default.) A Surrogate is a person who, by default, becomes the proxy decision maker for an individual who has no appointed agent.
Services provided to individuals age 60 and older which are funded under Title III of the Older Americans Act. Include: congregate and home-delivered meals, supportive services (e.g., transportation, information and referral, legal assistance, and more), in-home services (e.g., homemaker services, personal care, chore services, and more), and health promotion/disease prevention services (e.g., health screenings, exercise programs, and more).
Title XX Services are grants given to states under the Social Security Act which fund limited amounts of social services for people of all ages (including some in-home services, abuse prevention services, and more).
Provides transportation for older adults to services and appointments. May use bus, taxi, volunteer drivers, or van services that can accommodate wheelchairs and persons with other special needs.
A Treatment Plan is a written document which outlines the types and frequency of the long-term care services that a consumer receives. It may include treatment goals for him or her for a specified time period.
A Department of Defense program supporting private sector care for military dependents.
Service provided by physicians and hospitals for which no payment is received from the patient or from third party payers.
People with public or private insurance policies that do not cover all necessary medical services, resulting in out-of-pocket expenses that exceed their ability to pay.
Aid and Attendance is a benefit paid by Veterans Affairs to a veteran, veteran’s spouse, or surviving spouse needing home care, personal care/assisted living or long-term nursing home care. There are income and asset limitations for eligibility. There are other benefits programs for veterans in addition to Aid and Attendance. Go to the Veterans Administration website for additional information.
An individual must have a partial or total impairment by injury or disease incurred or aggravated during military service. A Veterans' Affairs (VA) rating board employs criteria developed by the VA to rate the extent of a disability.
An individual must have an injury or disease sustained outside of military service regarding a veteran permanently and totally impaired. Impairment is determined based on the veteran's ability to function at work and at home.
Veterans' Affairs (VA) hospitals are required to provide care to Class A veterans defined as those: rated as "service-connected; retired from active duty for a disability incurred or aggravated while in military service; in receipt of a VA pension; eligible for Medicaid; a former POW; in need of care for a condition that is possibly related to exposure to dioxin or other toxic substance; in need of care for a condition possibly related to exposure to radiation from nuclear tests or in the American occupation of Japan; or has an income below $16,466 with no dependents; or $19,759 with one dependent (with $1,055 added for each additional dependent). VA hospitals provide care on a space-available basis to persons in Category B veterans, those whose disabilities are not service-connected and have incomes above $16,466 but below $21,954. (Category C veterans have higher incomes and must pay a copayment.)
A dynamic state of physical, mental, and social well-being. Wellness is a way of life which equips the individual to realize the full potential of his or her capabilities and to overcome and compensate for weaknesses. It is a lifestyle which recognizes the importance of nutrition, physical fitness, stress reduction, and self-responsibility.
Forgoing or discontinuing life-sustaining measures.