Consider the below case study:

Margret Spinner-Ramirez is a 66 y/o female Hispanic-American who speaks both Spanish and English fluently. She is retired, lives alone, and has Medicaid as her primary insurance.  Ms. Spinner-Ramirez was scratched by a stray cat that she feeds on her back porch daily. She has been cleaning the wound daily; however, after 2 days she went to her local ER for increased pain, redness, and swelling in her left lower leg wound where she was scratched by the stray cat.  Ms. Spinner-Ramirez explained she recently had her left knee replaced about 6 months ago and verbalized new difficulty with baring weight on that extremity to the point that she was having to use her cane again. Her vital signs at the ER visit were stable.  Her left leg wound was cleaned and redressed.  After 5 hours in the ER, Ms. Spinner-Ramirez was discharged to home on oral Keflex for her left lower leg infection and was instructed to call her primary care physician for a follow-up appointment. Five days later Ms. Spinner-Ramirez was taken back to the same ER via ambulance.  Her neighbor found her lethargic, short of breath, and was experiencing difficulty being able to move. A CT scan and blood work revealed that Ms. Spinner-Ramirez’s knee replacement in her left leg was infected secondary to the cat scratch. She was admitted as an inpatient for sepsis. She needed to have a second left knee replacement surgery with wound irrigation and debridement, which extended her inpatient stay to 3 weeks.  Once she was discharged to home she required six weeks of IV antibiotics, extensive rehab, and home health. 

If you were in charge of a healthcare insurance company:

• Explain why insurance companies (which are considered payers) should or should not pay (reimburse) for injuries, extended costs, readmissions, or death (mortality) from a hospital-acquired infection or medical error. Support your why or why not? 
• Describe two ways (initiatives) healthcare quality can be improved to help reduce errors and improve patient safety. 
• Discuss how creating incentives for providers (healthcare organizations) can improve quality and reimbursements (payments) for services/care.

Textbook and other resources:

• Understanding Health Insurance
• What’s Behind the Health Insurance Rankings
• Hospitals will have to Pay for their Mistakes
• Medical Errors: Focusing More on What and Why, Less on Who
• National Business Coalition on Health: Health Care Purchaser Toolkit
• Agency for Healthcare Research and Quality

The Challenge and Potential for Assuring Quality Health Care for the 21s…

The Challenge and Potential for Assuring Quality Health Care for the 21st Century

All submissions must have a minimum of two scholarly references to support your work. 

Examples of work to show mastery:

• 2-3 page paper – APA format

 

 

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Read the following case study and answer the questions below. Response should be at least 75 to 100 words.

Wayne is a public health/community nurse who lives in South Texas. During the summer, Wayne’s community experienced uncontrollable wildfires that devastated the area. Because he lived in the area, Wayne was called upon to help triage and care for victims of the fires. Many of the wildfire victims were Wayne’s family, personal friends, and work colleagues.

1. After the fires were controlled and the most critically ill residents were transported to the hospital, Wayne began recovery efforts. What is Wayne’s priority recovery goal for this population? What steps should Wayne take to reach this goal? 
2. Wayne performs psychosocial assessments on the wildfire victims. Which victims are more likely than others to need crisis intervention? 
3. Wayne is worried about the major health concerns after a disaster and how they may affect his community. What are some of these major health concerns? What can Wayne do to improve the health concerns? 

 

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Case Studies Activity Instructions

Case studies are stories. They present realistic, complex, and contextually rich situations and involve problems to solve and/or questions to answer. Thoroughly read the case studies below and answer the questions presented in each. Your responses to the questions must be detailed and include information supported by academic sources (textbook, .gov, and .edu webistes). Do not use .com, .net, .org, or blog websites. All sources must have been published within the last 5 years.

Please complete all 3 case studies. Your case study responses must follow current APA format and include in-text citations for any resources you use to support your answers. You must also include a separate reference page. The Case Studies Activity must be submitted as a Microsoft Word document.

This assignment is due by 11:59 p.m. (ET) on Monday of Module/Week 2.

Case Study 1

Mrs. Jones, who is 80 years old, presents to ABC Medical Associates today for her annual wellness visit. She was last seen 6 months ago by a doctor in the practice for a bout with influenza.

In today’s visit, the patient will receive her annual gynecological evaluation in addition to a general maintenance examination. She will also have blood work done to evaluate her hypertension, hypothyroid, and type II diabetes.

Mrs. Jones is covered by Medicare and AARP Medigap insurance.

Based on the information in this case study, determine if this is a new or established patient. Then, describe what information you will need to collect from the patient and what steps you must take to ensure the services being rendered will be covered by insurance. Determine which insurance policy is primary.

Case Study 2

Mr. Jones is seen in the ER at Grand Valley Hospital for chest pain. He is from another state and is visiting family. He has never been to Grand Valley Hospital previously.

While in the ER, it is determined that the patient needs a cardiac catheterization done before discharge. This procedure is performed by Dr. Lindsay.

Mr. Jones serves in the National Guard and has been covered by TRICARE since 1989. He is also covered by his employer’s health plan, Blue Cross Blue Shield, and has been covered by this health plan for the past 2 years.

Based on the information in this case study, determine if this is a new or established patient. Then, describe what information you will need to collect from the patient and what steps you must take to ensure the services being rendered will be covered by insurance. Determine which insurance policy is primary.

  

Case Study 3

Jack Minnow, a 4-year-old boy, presents to Valley Allergy practice because of a recent allergic reaction to a bee sting. He has never had a reaction previously. Jack’s primary care physician Dr. Zane is referring him to Dr. Shelby, an allergist, for a consultation. Jack is accompanied by his mother who is the custodial parent.

During the visit, Dr. Shelby performs a series of allergy tests that identify not only an allergy to bees, but also to animal dander and grass.

Jack is covered by both his mother’s and his father’s employers’ health plans. His parents are divorced. His mother went back to work after the divorce 1 year ago and enrolled Jack under her health plan due to some concerns about whether Jack’s father would keep his job. However, his father is still employed with the same company and has worked there for the past 3 years.

Based upon the information in this case study, determine if this is a new or established patient. Then, describe what information you will need to collect from the patient/guarantor and what steps you must take to ensure the services being rendered will be covered by insurance. Determine which insurance policy is primary.

 

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answer to questions

 

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