Part 1
1. I am interested in your ideas on how managed care organizations can more effectively prevent diseases or more specifically preventing the spread of disease among its contracted population. In other words, what can HMOs do to promote health and reduce illness rather than treating it after the fact. Address cost implications, patient receptivity, provider cooperation and other factors impacting this issue.
2. One of the cornerstones of Accountable Care Organizations is the use of Evidence-Based Medicine. What is this, what are the negatives of EBM, and how can HMOs encourage the positive benefits of EBM.
3. The Health Care Industry has espoused “quality management” for decades. Please identify and briefly discuss three quality management processes, at whatever level you wish (insurance companies, hospitals, medical groups, nursing homes, etc.).
Part 2
1. Years ago it was quite common for HMOs to offer a wide range of behavioral health services, including in-patient hospitalization. More recently, HMOs have limited in-patient programs and encouraged out-patient services. Discuss some of the reasons for this shift.
2. One of the benefits to patients joining an HMO is the relatively strict peer-review and physician credentialing process required for accreditation. Discuss why the credentialing process is important and how it relates to quality management.
3. Discuss how managed care organizations design, market and sell their products to consumers, including individuals and companies.
4. Years ago when I worked for an HMO is Arizona, we contracted with a private company to provide our HMO with hospital discharge and cost data by physician specialty. We used this data to contract with the more cost effective physicians in the State. In effect, we were “provider profiling”. What are some of the potential negatives with using this type of data in the provider contracting process?
Part 3
1. In an attempt to improve quality in managed care, a report called HEDIS was established and expanded upon over the years. What is HEDIS and what is its proported value to health care?
2. One of the most important documents established between a contracted medical group and an HMO is a DOFR (Division of Financial Responsibility). Discuss the DOFR and identify three reasons why this document is important.
3. The American Recovery and Reinvestment Act of 2009 included a provision to establish the HITECH Act (Health Information Technology for Economic and Clinical Health Act). Identify and discuss three provisions of this Act.
4. Identify and discuss three basic ways to ensure the accuracy of claims processing within managed care.
Part 4
1. ACA requires HMOs to achieve a certain “medical loss ratio”. What is a “medical loss ratio” and why is this an important issue?
2. After the passage of Medicare, the federal government has played a major role in setting health policy. Identify and briefly discuss three federal laws regulating health care which have had a material impact on HMOs and the health care industry in general.
3. Over a dozen years ago, California established the Department of Managed Health Care, one of the first in the nation to recognize that HMOs were different from other forms of health care insurance. Please identify and discuss three major functions of this Department.
4. Incurred But Not Reported (IBNR) in claims processing can (and has) led to insolvency on the part of some medical group. Discuss IBNR and identify several ways capitated medical groups try to address this issue.
5. There are two basic methods HMOs (and other insurance companies) use to rate the risk of providing insurance to employers: experience rating and community rating. Briefly discuss each method and explain the merits and problems associated with each method.

Respond to the assigned Discussion about (ARDS & VAP) give a complete and thorough answer
Remember to cite one reference from the
A peer reviewed journal article Database Collection. Respond to at least two of your
colleagues answers and reference your responses. The grade on this discussion will be based on
your initial response to the discussion and two responses to your colleagues post. For each
response cite a reference.
Discussion responses will generally be at least 200 words. All entries should use appropriate
grammar and follow general APA guidelines.Discussions
Instructions: Respond to the assigned Discussion and give a complete and thorough answer
(Review the Discussion Question Rubric. Remember to cite one reference from the
A peer reviewed journal article Database Collection. Respond to at least two of your
colleagues answers and reference your responses. The grade on this discussion will be based on
your initial response to the discussion and two responses to your colleagues post. For each
response cite a reference.
Discussion responses will generally be at least 200 words. All entries should use appropriate
grammar and follow general APA guidelines.DISCUSSION BOARD QUESTION #1
(Needs to be answered)
2. Patient Positioning
Discuss patient positioning for the patient with Acute Respiratory Distress Syndrome including the use of prone positioning. What is the current evidence for turning schedules in this patient population.
REPLY TO THE FOLLOWING TWO POST:
Respond to at least two of your colleagues answers and reference your responses. Discussion responses will generally be at least 200 words. All entries should use appropriate grammar and follow general APA guidelines.
Colleagues POST #1
The question asked:
Describe the pathophysiology of Acute Respiratory Distress Syndrome. List 3 interventions and describe how each should improve oxygenation.
Acute Respiratory Distress Syndrome (ARDS) can be a life threatening condition if not diagnosed and corrected quickly. ARDS can be diagnosed with the criteria of: hypoxemia refractory to oxygen administration decreased pulmonary compliance dyspnea pulmonary edema from non-cardiac causes and pulmonary infiltrates noted on X-ray (Ignatavicius& Workman 2016). Often caused by trauma ARDS can be seen in patients with previously healthy lungs. I recently cared for a woman laboring in ARDS. Her cause was not trauma but regardless of the etiology the underlying mechanisms of action are the same. The main problem is the systemic inflammation that occurs in the alveoli (Ignatavicius& Workman 2016). This inflammation along the capillary exchange allows the cell walls to become expanded and therefore more permeable to fluids and other molecules when the primary intention is permeability of oxygen molecules. Due to this the fluid begins to penetrate the alveoli and cause protein saturated fluid to pool inside the tiny structures (Ignatavicius& Workman 2016); thus the decreased oxygen saturations to the lungs and other tissues. The decreased lung compliance is caused by the decreased production of surfactant from damaged pneumocytes and the dilution of surfactant from additional fluids (Ignatavicius& Workman 2016). Due to these changes the alveoli become difficult to expand and can collapse further contributing to the poor gas exchange (Ignatavicius& Workman 2016). These mechanisms result in the difficult labored breathing noted on assessment and the fluid noted upon chest X-ray. Interventions to relieve the symptoms of ARDS include intubation with CPAP to apply a positive airway pressure and prevent alveolar collapse and improve alveoli participating in gas exchange (Ignatavicius& Workman 2016). Positioning and every 2 hour position changes are also an important intervention. This allows improved gas exchange and improved perfusion (Ignatavicius& Workman 2016). Other interventions can include medications to fight infections and fluid restrictions (Ignatavicius& Workman 2016). The fluid restriction was key in my ARDS patient. Until the inflammation of the membranes subsided the fluid would continue to cross the barrier into the alveoli. By limiting fluid intake and in this case adding Lasix the excess fluids were slowly pulled back into the vascular beds circulated appropriately and ultimately excreted. This took several days before marked improvement was noted in the patients respiratory assessment. The rapid recognition and appropriate treatment are critical in the recovery of these patients.Ignatavicius D. D. & Workman M. L. (2016). Medical surgical nursing: Patient-centered collabrative care. St. Louis MO: Elsevier.Colleagues POST #2Respond to at least two of your colleagues answers and reference your responses. Discussion responses will generally be at least 200 words. All entries should use appropriate grammar and follow general APA guidelines.
The question asked:
Describe best practices for patient safety and quality care for the prevention of Ventilator Associated Pneumonia (VAP) in the mechanically ventilated patient.
Ventilator Associated Pneumonia is a condition characterized by a lung infection in patients who are on a ventilator breathing machine. According toIgnatavicius & Workman (2013) VAP is a type of hospital acquired pneumonia where the mortality rate increases based on the type of microorganism that is present; such are Klebsiela and Acinetobacter. VAP infections rates are increasing with patients who are intubated. The authors continues by saying research indicates that a VAP bundle when utilized effectively by nurses has shown to decrease infection rates. The VAP bundle focuses on three areas head of bed elevated hand hygiene and oral care (Ignatavicius& Workman 2013).
Working in an Intensive Care Unit I am very familiar with VAP bundle. Every shift we have to audit the previous nurse to make certain they have documented in the three areas plus several other areas of the VAP bundle. However it is important to note nurses must actually perform the interventions and of course document them afterwards.
Best practice for patient safety quality care and evidence based research also indicates that the following are effective measure to prevent or decrease VAP rates; refrain from wearing jewelry on the upper distal extremities head of bed at least 30 degrees disinfect mouth prior to intubation perform proper hand hygiene suction every two hours full mouth care once per shift wean trial should begin as soon as possible always verify initial x-ray for endotracheal tube and oral/nasogastric tube before giving fluids and use caution when moving patient especially within one hour of feeding (Ignatavicius & Workman 2013).
In one recent scientific journal VAP bundle has been associated with a reduction of infections and the ICU where the study was conducted saw its VAP rates cut dramatically. Additionally the Institute for Healthcare Improvement (IHI) developed a VAP bundle that included the following; daily sedation vacation readiness to wean head of bed elevated and peptic ulcer prophylactic treatment which are also part of the best practice for patient safety and quality care initiative (Beattie Shepherd Maher & Grant 2012).
Beattie M. Shepherd A. Maher S. Grant J. (2012). Continual improvement in ventilator acquired pneumonia bundle compliance: A retrospective case matched review. Intensive & Critical Care Nursing 28(5) 255-262. Retrieved from http://eds.b.ebscohost.com.libproxy.lamar.edu/ehost/pdfviewer/pdfviewer vid=10&sid=080e8ffc-938c-459a-ab00-badd80ebe12c%40sessionmgr110&hid=122
Ignatavicius D. D. & Workman M. D. (2013). Medical-surgical nursing patient-centered collaborative care (8th ed.). St. Louis Missouri: Elsevier.