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Ambulatory and Primary Care What Is Ambulatory Care?

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Ambulatory and Primary Care What Is Ambulatory Care? © Ambulatory and Primary Care 1 © Presentation Objectives o Define ambulatory care o Define primary care o Explain subsets of ambulatory care o Explain ambulatory care and accreditation o Challenges and future of ambulatory care 2 © What is Ambulatory Care? oDefine ambulatory care oDefine primary care oExplain subsets of ambulatory care oExplain ambulatory care and accreditation oChallenges and future of ambulatory care 3 1 © What is Ambulatory care? • Personal health care provided to individuals who are not occupying a bed in a health care institution or in a health facility. • Ambulatory care vs. primary care • Follow-up care following inpatient episodes • A contemporaneous shift to ambulatory care 4 © Where is Ambulatory Care Service Provided? In a variety of settings, including: Freestanding provider offices Hospital-based clinics School-based clinics Public health clinics Community health centers 5 © Ambulatory Care Visits Number of Ambulatory Care Visits 7.5 7.5 8 7 6 393.9 5 3.1 4 2.1 3 1.5 2 1 0 15‐24 25‐44 75+ Male Female 6 Source: Health United States 2000 (1998 data) 2 © Physician Office Visit (National Center for Health Statistics. 2006) 7 © Physician Office Visit (National Center for Health Statistics. 2006) 8 © Physician Office Visit Data‐1: (National Center for Health Statistics. 2006) Trend of Office Visit by Type of illness and Season 9 3 © Ambulatory Care Visits: Physician‐visits by Race Number of Ambulatory Visits by Race 90 80 70 60 50 40 30 20 10 0 ER Hospital Outpatient Physician's Office Black White Other 10 © Annual rate of visits to office‐based physicians by patient race and ethnicity 11 (National Center for Health Statistics. 2006) © Trends in Ambulatory Care Visit (1980‐1990‐2000) Trends in Ambulatory Care Visits (% of Visits) 60 50 40 30 20 10 0 Primary Care Visits General/Family Practitioner Internist Pediatrician 1980 1990 2000 12 Source: US Dept. of HHS 2000 4 © Organization of Ambulatory Care Services • Two major categories 1. Physicians offices (solo, group, managed care) 2. Hospital based ambulatory services – Clinics – Hospital sponsored group practice – Health promotion centers – Free standing surgical centers – Etc… 13 Composition of total ambulatory care visits Emergency Department 10% Hospital Outpatient 7% Physician Office 83% 14 © Reasons for physician office visits Why do people go to the physician's office? 30 28.1 25 19.9 18.2 20 17.5 15 11.9 10.4 8.7 10 8.3 7.3 7.8 6 4.9 5 1.5 0.7 0 Arthritis Chronic renal COPD Depression Diabetes Hypertension Obesity failure 1995 2005 15 5 Office visits by phsycian specialty (2005) Source: CDC All others General and family 29% medicine 22% Internal medicine 17% Orthopedic surgery 5% Ophthalmology Pediatrics 6% 14% Obstetrics and gynecology 7% 16 © Primary Care oDefine ambulatory care oDefine primary care oExplain subsets of ambulatory care oExplain ambulatory care and accreditation oChallenges and future of ambulatory care 17 © What is Primary Care? Primary care is the provision of integrated, accessible health care services by professionals who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community (Institute of Medicine, 1999) •Keywords •Community •Sustained partnership 18 6 © Primary Care Providers • The providers of Primary Care fall into four major disciplines: Physicians Nurse Practitioners (NP) Midwives Physician Assistants (PAs) 19 © Percent of services delivered by Primary care providers Midwifes Nurse practitioners Physician assistants Physicians (95.2%) 20 © Out Patient Visit: Children under 18 21 7 © Out Patient Visit: by patient age and sex: 2004 22 National Center for Health Statistics. 2006 © Out Patient Visit: by patient age: 2004 23 National Center for Health Statistics. 2006 © Out Patient Visit: by patient age and sex: 2004 24 National Center for Health Statistics. 2006 8 © Out Patient Visit: by patient age, race and ethnicity (2004) 25 National Center for Health Statistics. 2006 © Out Patient Visit: by source of payment : 2004 26 National Center for Health Statistics. 2006 © Out Patient Visit Rising role of midlevel providers 27 National Center for Health Statistics. 2006 9 © Subsets of Ambulatory Care oDefine ambulatory care oDefine primary care oExplain subsets of ambulatory care oExplain ambulatory care and accreditation oChallenges and future of ambulatory care 28 © 1. Emergency Care 29 © Emergency Care Service • Definition: – inpatient and outpatient services needed to evaluate or stabilize an emergency medical condition • An emergency medical condition: one that manifests itself by acute symptoms of sufficient severity 30 10 © The U.S. Emergency System • 911 Response System • Hospital based emergency services – Different levels of trauma hospitals – 24/7 capability – Over 92.6% of hospitals have an ED • Treatment for acutely ill, injured, walk ins • Evaluation prior to admission • Volume: approximately 100 million 31 © Emergency care (contd.) o Categories of patients entering through the ER 1. Emergent: Patient should be seen in less than 15 minutes. 2. UtUrgent: PtiPatien t shldhould be seen within 15‐60 minutes. 3. Semi‐urgent: Patient should be seen within 1‐2 hours 4. Non‐urgent: Patient should be seen within 24 hours. 32 Categories of patients receiving emergency care Emergent Unknown (no 13% triage) 15% Non‐urgent 12% Urgent 38% Semi‐urgent 22% 33 National Center for Health Statistics 2000 (1999 data) 11 © Relevant Developments Emergency Care • Walk‐in units to relieve the volume of emergency services • Financial pressure to divert non‐urgent patients • Pre‐emergency department care 34 Percent distribution of ambulatory care visits by setting type (2004) Medical specialty offices 18% Primary care offices Surgical specialty 48% offices 16% Emergency departments 10% Outpatient departments 8% 35 36 12 © What time is it? Average length of time for duration of office visits and emergency department waiting times 47.4 50 45 38 40 35 30 25 18.6 18.7 20 15 10 5 1994 2004 1994 2004 0 Office visit duration Waiting time in emergency departments 37 © ER Visit: Seasonal variation in selected reasons by Calendar Quarter 38 National Center for Health Statistics. 2006 © ER Visit: by Age Group : 2004 39 National Center for Health Statistics. 2006 13 © ER Visit: by Age, Race and Ethnicity : 2004 40 National Center for Health Statistics. 2006 © ER Visit: by Primary Source of Payment : 2004 41 National Center for Health Statistics. 2006 © ER Visit: by Mean Waiting Time : 2004 42 National Center for Health Statistics. 2006 14 © 2. Subspecialty Care 43 © Subspecialty Care • Definition – Care given by physicians who are not generalists – Ambulatory – Generalists: family medicine, general pediatrics, general internal medicine, geriatric medicine, and general OBGYN – Subspecialists: all others • Care that is not appropriate in primary care setting • Referral through primary or direct contact by patient 44 © From inpatient to ambulatory Surgery Surgeries per 1000 people 60 50 40 30 20 10 0 Ambulatory Surgery Inpatient Surgery 1994 1998 45 15 © Growth in percentage of outpatient surgeries Percent of surgeries performed in ambulatory settings 61.7 54.9 16.4 1980 1993 1998 46 © 3. Home Health Care 47 © Home Health Care • What is it? – A wide variety of care services provided or delivered to the patient’s home – Typically ordered by a physician and medically necessary – Per visit versus per hour – Who gets it? 48 16 © It can be high tech… o Infusion Therapy (IV/pumps) o Home Uterine Monitoring o Ventilator Management o Heparin The rapy (a nti-coagul ant ) o Chemotherapy o Compounding of Drugs o Diagnostic Services, Lab/x-ray 49 © Skilled Professional home health agency services include: o Nursing provided by a registered nurse (RN), nurse practitioner (NP), or a licensed practical nurse (LPN). o Phyypysical Therapy o Occupational Therapy o Speech Therapy o Medical Social Work o Respiratory Therapy 50 © It can also be not‐so‐high skilled labor Paraprofessional home health agency services include: o Home Health Aides o Personal Care Assistants o Physical Therapy Assistants o Certified Occupational Therapy Assistants (COTA) Custodial home care services include: o Homemaker and housekeeping Mostly for aged o Companions population and in o Private duty help recovery/rehab phases from major o Live-in services procedures o Hourly or shift coverage 51 17 © Home Medical Equipment Home Medical Equipment services include providing durable medical equipment, such as: o Artificial limbs o Prosthetics o Beds o Braces o Canes o Crutches o Wheelchairs o Commodes o Respiratory equipment (concentrators) o Oxygen 52 © An Example: Hospice Care • Hospice care at home is often preferred by patients: – Psychologically better – Emotionally better – Spiritually better • Palliative care, pain management, physician services, etc… 53 © 4. Complementary & Alternative Medical Care 54 18 © What is complementary and alternative medical care? • In 1992, Congress established the Office of Alternative Medicine (OAM) – Determine effectiveness of alternative medical care • National Center for Complementary and Alternative Medicine (NCCAM) – “ those treatments and healthcare practices not taught widely in medical schools, not generally used in hospitals, and not usually reimbursed by medical insurance companies” 55 © Types of CAM practices with examples 1. Alternative Medical systems – Ayurveda, homeopathy, naturopathy 2. Mind‐Body Interventions
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