A nurse is working with a case manager for a client who participates in a health maintenance organization.
The nurse should identify that a health maintenance organization provides which of the following payment structures?
The provider bills the client directly for a predetermined percentage of the cost of services.
The client pays the insurer a percentage of the total costs for each service rendered by the provider.
The client is participating in a fee-for-service healthcare insurance program.
The provider is paid a fixed sum for the client on a monthly or yearly basis.
The Correct Answer is D
In a health maintenance organization (HMO), the provider is paid a set amount of money for each client enrolled in the program. This payment structure is known as capitation.
The provider is responsible for providing all necessary healthcare services to the client within the confines of the capitated payment.
The client is not required to pay the provider directly for any services rendered within the HMO network.
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Related Questions
Correct Answer is A
Explanation
Case management is a collaborative process that involves assessing, planning, implementing, coordinating, monitoring, and evaluating the options and services required to meet the patient's health needs. The case manager is responsible for evaluating the patient's needs and developing a care plan that meets those needs. The case manager works closely with the patient, their family, and the healthcare team to ensure that the care plan is being followed and adjusted as necessary.
Teaching a smoking cessation support group, performing employee risk assessments, and familiarizing with OSHA Standards in the workplace are not responsibilities of the case manager. These tasks are typically performed by other healthcare professionals such as nurses, occupational health nurses, or environmental health and safety professionals.
Correct Answer is B
Explanation
Before discussing specific aspects of the client's care, the nurse should assess the client's living environment to determine if it is suitable for the client's needs. In this case, the client requires a special bed to manage the pressure injury, so the nurse should assess if the client's current living environment can accommodate this need.
If the client's current living environment is not suitable, the nurse can work with the client and their family to identify alternatives, such as modifying the current environment or finding a new living arrangement. Once the nurse has assessed the living environment, they can proceed to discuss specific aspects of the client's care, such as accessing supplies, nutrition, and wound care.
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