HEALTHCARE AT ALTERNATE SITES 1

Healthcare at Alternate Sites Study Journal

Erynn Dunnigan

University of Mary: RTH 411 01

Professor Erin Haustveit

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Breakout 1 and 2
September 7, 2023
My Reflections
Course Quotes:
1) What groups are at greater risk for Medicaid
”An analysis of churn coverage loss during this unwinding period?
rates among children Individuals who have recently moved, immigrants, LEP,
found that while churn disabilities, and older adults.
rates increased among
2) Are children impacted by this? What data are
children of all racial and
ethnic groups, the you able to find to support your answer?
increase was largest for Rates for children will be increased on average however a
Hispanic children, larger impact will be on children of Hispanic descent and those
suggesting they face with language barriers. Children in states w/o the 12 month
greater barriers to continuous enrollment are at higher risk because each state
maintaining coverage.” accompanies coverage and usually you have to reapply if you
(Tolbert & Ammula, are not re-enrolled because they have to continuously reapply.
2023.)
Takeaways from article (Bradley Curallo, 2023.):
1) “At the start of the pandemic, Congress enacted the
Families First Coronavirus Response Act (FFCRA),
which included a temporary requirement that
Medicaid programs keep people continuously
enrolled and, in exchange, states received
enhanced federal funding. “ (Bradley Curallo, 2023.)
This is etiology for this crisis.

2) ” Overall, 65% of the people had a gap in coverage

during the year following disenrollment from
Medicaid/CHIP and only 26% of people enrolled in
and retained another source of coverage for the full
year after losing Medicaid/CHIP coverage.” (Bradley
Curalo, 2023.)
Many are being disenrolled in Medicaid however are likely
still eligible. 2/3 people being dis enrolled are not provided
with an alternative to use for coverage.

Video
1) What is driving high healthcare costs in the
United States?
The global pandemic has had a very large impact on an
already struggling and understaffed healthcare system
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in the United States The American Hospital

Association (AHA) reports following the year 2022
that, “Critical workforce shortages forcing hospitals to
rely heavily on more expensive contract labor, led to
2022 being the most financially challenging year for
hospitals since the pandemic began. Moreover,
sustained demand for hospital care with patients
coming to the hospital sicker and staying longer has
exacerbated these challenges. (American Hospital
Association 2023) Other major contributors to the lack
of funds include an increase in hospital expenses and a
decrease in Medicaid coverage. The hospitals are
eating the cost by more than double the amount they
had. “Hospitals’ labor expenses, which on average
account for about 50% of a hospital’s budget, are up
20.8% from 2019 to 2022” (American Hospital
Association 2023). The higher patient quota has
resulted in higher demand for expensive equipment
such as ventilators. As the demand increases,
government funding falls further short of compensation
and managing the rising cost in healthcare.

2) Research Value Based (Patient Centric

Care) Systems.
Patient centric care is a model aimed to better sustain
patients with more intensive healthcare needs- those
who need the most assistance. It aims to support what
the patient desires to support in their health. It is aimed
to be more individualized and holistic. In a peer review
assessing the effectiveness of patient centric care it
reveals that, “the U.S. health care system meets the
needs for some while failing to achieve patient
centeredness for subsets of individuals. In these latter
cases, there are barriers that impede delivery of patient
centered care to specific sub-populations, and
interventions must be tailored to these groups”
(Sinaiko, 2019). It focuses on goals and needs of the
patients by providing access, accounting for life
circumstances, values and culture, care preferences,
health status, and symptoms all encompass value-based
care (Sinaiko, 2019). Currently, the United States
continues to struggle with financing our medical staff
and shifting back from a business to a patient centered
model. This article assessed that the four main barriers
for the US to achieving such are, “ (1) understanding
the patient context: important information & how to
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collect it; (2) building trust & mutual respect between

patients and providers in the health care system; (3)
aligning incentives with patient-centered care; and (4)
creating a culture of medicine that delivers patient
centered care (Sinaiko, 2019).

Due Date: 9/13/23 1. How much did you know about the American
Reflection 1: Video
Health Care System prior to reading the
Reflection
information provided and watching the videos?
Prior to watching the video, I felt well versed in our
healthcare system, especially insurance policies. I have done quite a
bit of my own research on how this works with HSA, billing,
deductibles, and private versus public insurance this past year as I
have navigated my own coverage. It has caused me to think about
how difficult it can be for so many people with what we have set
up, and most concerningly, the Medicaid crisis. However, I was not
extensively familiar of other countries’ health care systems. I
mostly had a general idea of how Canada, Japan, and Britain
functioned- though I certainly learned more about each of theirs
amongst others.

2. How does the American Health Care System

differ from the Saudi Arabia Health Care
System?
Saudi is similar to us in terms of private and public insurance
routes are made available (Alasiri & Mohammed, 2022). The
primary service that is provided is called the Ministry of Health
(MOH) and this is the foundation of care there- higher levels of
care there are referred to as secondary and tertiary care- similar to
us. Unlike us, their health funding is highly dependent on their
crude oil production and sales, and while this may impact the
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spending for us it is secondary and not as direct as the impact in

Saudi (Alasiri & Mohammed, 2022). They are undergoing large
changes to their system- a full reorganization referred to as The
National Transformation Program or Vision 2030. The goal with
vision 2030 is to decentralize the healthcare system for better
dispersal for the population, further privatization of care(Al-
Amoudi, 2017). Overall, healthcare is viewed as an innate right to
the people in Saudi with the integration and utilization of MOH,
they have mandatory coverage since 2008 and there is a penalty if
you do not (Al-Amoudi, 2017).

3. How do you feel about the US health care

system after you have learned about health care
models in other developed countries? Provide
rational for your response.
I was very surprised to learn about the Japanese health care
system and imaging such as MRIs are so reasonable and
standardized (PBS 2008). Multiple studies have found that the
Japanese spend on average 50%less on healthcare and live 6 years
longer than the average American (Interac, 2023). The statistic
from the video mentioned that the Japanese goes to “three times
more to healthcare appointments per year than residents in the
United States” (PBS, 2021). Another aspect I found interesting was
in Britain, there is an incentive for physicians to treat their patients
well and demonstrate success. I wonder how this works in practices
such as hospice and palliative care in their country. The Bismarck
model in Germany was also interesting to learn about and how it is
utilized so much on a global scare – everyone gets the care that
they need. However, the downside to the system in Japan and in
Germany is that it is difficult for doctors to feel motivated and
compensated fairly.

4. In your opinion is health care a right or a

privilege? Provide rational for your response.

Even here in our country, in Health care: America vs. the world
emphasizes that we have many people, in their example individuals
in Houston Texas, that have very limited access to healthcare here-
financially and physically. We are lacking in this way- thus it is not
a privilege but rather a right. Harvard Public Health emphasizes
that the United States is the only high-income country to not have
universal access to healthcare (Mollmann 2023). We have people
working in healthcare like Lakeisha Parker, who cannot even afford
and maintain her own healthcare and later qualifies for coverage
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following a cancer diagnosis (PBS 2008). We are lacking in

preventative medicine- and to me, preventative medicine, proactive
health is the only chance for curative medicine – to succeed in this,
we must see medicine as a right to all and not a privilege to some.

5. If you had to choose a health care model, which

of the models discussed in the videos would you
pick? Provide rationale for your response.
“America is not really a system that one can copy, it is a market.” -
Dr. Hongjen Chang
Taiwan utilizes a one insurance system (similar to Medicare) and it
is priced the same. There is not a long wait to see specialists, they
have the lowest administrative costs in the world (PBS, 2021).
They emphasize that “Taiwanese citizens can see any doctor
without a referral. They may also go to any level of hospital
directly, as they wish” (Wu, Majeed, & Kuo, 2010). Patients do not
go broke from healthcare; however, the system is strained- but so is
ours. In this sense I think of it as minimizing the pitfalls, the benefit
to Taiwan is that it reduces unemployment and financial burden in
access to healthcare- both of which promote a healthier
socioeconomic status and better access than what we are
experiencing here today.

Breakout 3 and 4 Health Insurance Quiz

9/12/23 You Answered 10 out of 10 Questions Correctly.
Compared to a nationally representative sample of U.S.
adults, you scored the same as 4% and better than 96%
Question post quiz: How do deductibles offered in plans get
decided?

Coverage to Care
Group 4: Read the section on Find a provider (page 20-23)

o What are referrals?

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Referrals are needed when your care

demands go beyond your primary care
provider (PCP), often times requiring
medical evaluation in other specialties.
Referrals are sent from your PCP to the
specialist and can often times be necessary
for insurance to assist in paying for seeing
that specialist.

o What are pre-authorizations or prior

authorizations?

Preauthorization is a requirement put in

place by some insurers in order for them to
cover a specific aspect of care – that care
must be deemed medically necessary prior to
them assisting with the expense- this is
considered preauthorization.

o Summarize the reading to help the class

understand the importance of knowing their
plan before choosing a provider.

It is important to check with your insurance

provider prior to acquiring health expenses
and go through their proper protocol such as
attaining a referral prior to seeing a specialist
so they can help cover the costs. The same
goes for the treatments that are given during
those visits and checking to see if
preauthorization is needed or else you may
be charged more. It is also important even
after attaining a referral, to see if that
provider is in network- because out of
network providers will often cost
significantly more than those in network.

9/20/23 Reflection 2 Healthcare Payment Terminology Takeaways

1) Deductibles are something I knew about and

have had experience with; however I was not
familiar with the term coinsurance. The concept
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of coinsurance is something I have also

encountered, I just didn’t know the term for it. I
decided to do more research on deductible plans.
According to the National Pharmaceutical
Council (NPC), more than one third of
Americans enrolled in employment plans choose
high deductible health plans (HDHP) compared
to 10 percent in 2010 (2022). The National
Pharmaceutical Council remarks on a evidence
based concerns with HDHP, “HDHPs are
intended to make enrollees more sensitive to the
costs of health care services to help lower
overall health care spending. However, they can
also create barriers to health care for people with
lower incomes or with chronic conditions
requiring regular provider visits or medications”
(2022). I understand that healthcare is expensive
and everyone needs to pay their dues, however I
do think this is a valid observation and a large
concern. With more people choosing such plans,
whether they do not intend to use it or they
simply cannot afford the higher premiums, they
sign up for something that if the time comes that
they need it- they can’t afford it. Or they are
deterred to get help because they have high out
of pocket costs. I grew up with very high
deductibles in my home and have experienced
this firsthand.
2) Another thing that I did not know was that
coinsurance and copays can be tax deductible if
you spend greater than 7.5 % of your income
and that what you spend above that you can
deduct from your taxes with some plans. I also
learned more about the out-of-pocket
maximums, I did not know about these until
after our class discussions.

3) When I contemplate my own health insurance in

the future, beyond what I have now. Ideally, I would
like to be able to do a high deductible health plan
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(HDHP) through my place of employment with a

lower monthly premium and a health savings
account, however, realistically I live with chronic
conditions on top of acute health struggles and need
daily prescribed medications along with rechecks
and lab work. For these reasons, practically I would
likely need to be starting with a higher monthly
premium so that I can have a lower deductible to
meet. It really just depends on who you are and how
much you utilize healthcare.

9/26/23 Reflection Discuss assumptions made during andragogy video:

 The need to know- why are we learning something and
what the benefits are and what’s the risk of not knowing.
Understanding the value in learning.
 Self- concept- we have a self-concept of being responsible
for their lives- taking initiative and self-management. In
adulthood we shift from a dependent to an independent
motivation.
 Experience- adult learners have experience more diverse
than children and learning can benefit from such-
singlemindedness may also occur—learning must be
associated with existed knowledge and be active and
constructive.
 Readiness to Learn- adults need learning to be timely.
 Orientation to Learn - learning must be experiential and
contextualize using concrete experiences to learn and then
use in further situations.
 Motivation to learn- could be extrinsic or more likely,
intrinsic in adults. Having choice and control and value over
what is learned.
*Adult learning is self-guided*

Reflection 3 How to Create and Design Helpful Patient Education

Due 9/28/23 Materials:

Matt Moneypenny emphasizes on his blog How to Create

and Design Helpful Patient Education Materials how
important post care instructions are for patients and states
that “patient’s who have a clear understanding of their post-
care instructions have a 30 percent less likely chance of
readmission compared” compared to those that do not
(2020). This is a large and significant statistic- 30 percent is
not just a number in this case- it is peoples lives and
wellbeing, and it is millions of dollars the hospital systems
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assume. We discussed in class how adults learn and I think

this is something that we can consider when providing such
impactful education- the example I liked in class was that
often times patients get their post assessment care in a
packet to read on their own or it gets reviewed at the end
once they are tired and overwhelmed and might not
understand a word of what was said the past hour. We can
take what we know about adult learning and spare the 30
percent.

I liked Matt’s suggestion when designing outreach for

patient education to utilize multiple platforms. He makes a
great point saying “making educational handouts aren’t for
the Millennials or Gen Z patients you see. Likewise, your
videos won’t get watched by many of the Baby Boomers
you care for” (Moneypenny, 2020). I think this is huge to
recognize and adapt to because we are in an extremely
transitional time for platforms of learning generationally.
We are undergoing major shifts with youth and young
adults relying completely on technology, other adults in the
middle, and an elderly population who many rely only on
paper mail and pencils. It is essential to reach and
accommodate all of these methods, most especially when it
pertains to their health.

Another interesting statistic he mentioned was regarding the

importance of including visual aids. He said, “When a
message and a visual exist together on the same page,
people can recall 65% of the information 3 days later”
(2020). This also a very useful thing that I plan to
implement into my own project and educational resources
for patients. Along with this however, I think it is important
to one) not overload patients with too much visual data to
look at and maintain simplicity, and two) not use visual
graphics just to have them- I think there are things that are
more effectively communicated with a chart or graph and
others that are not and it can as I said become excessive and
ineffective.

The last large takeaway that I had from Moneypenny’s

writing was to “use language in your copy that everyone
can understand. That way you’ll only need one master
version” (2020). This is so important with patient
communication in general, but especially in instructions that
could prevent them from suffering complications following
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discharge. I want to be very conscientious of this in my

work going forward because I know I tend to
overcomplicate things, and I know I love teaching and that
moment when what I say clicks for someone else- so I
really do want to find my balance in this. This will be good
practice for me and likely help with my efficiency and
effectiveness in patient care moving forward.

Breakout Reflection
10/3/23 Pulmonary Rehab Journaling:

1) How are patients selected for Pulmonary Rehab?

Patients qualify for PR programs is they have been

diagnosis with a chronic pulmonary or cardiac disease.
They also qualify following acute afflictions such as an MI
or PE. Patients that require home oxygen also qualify for
PR programs. If patients are in the hospital they can qualify
from their condition and may also do exercise testing such
as a 6MWT.

2) What patient disease processes might benefit from

Pulmonary Rehab? Why?

Per the AACVPR,

“conditions that are appropriate for pulmonary

rehabilitation include COPD (including alpha-1 anti-
trypsin), persistent asthma, bronchiectasis, cystic fibrosis,
ARDS survivors, chest wall diseases, kyphoscoliosis,
ankylosing spondylitis, post tuberculosis syndrome,
interstitial lung disease, interstitial fibrosis, sarcoidosis,
lung cancer, pulmonary hypertension, before/after lung
transplantation, before/after lung volume reduction surgery,
and obesity related respiratory disease” (AACVPR, n.d.)

3) What are the essential components of a Pulmonary Rehab

program?

The essential components of a PR program include:

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(Holland et al., 2021)

4) What is the role of "exercise testing?"

The 6MWT is utilized for pre and post op patients and other
admitted patients to determine morbitities with one’s
cardiovascular or pulmonary status. The CPET is ”used to
define which organ systems contribute to a patient’s
symptoms of exertional dyspnea and exercise intolerance
and to what extent. The test is also more sensitive for
detecting early or subclinical disease than are less
comprehensive tests that are done at rest” (Wood, 2023).

5) How are outcomes evaluated and measured for patients? What is

considered a patient "success story?"
Outcomes are measured by physiologic, lab and
psychosocial results. These are both qualitative and
quantitative results.
Other measurable outcomes include:
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(Palermo & Corrà, 2017).

These are measured using PFTs, echo, end tidal
measurements, cardiac monitoring, SpO2, and flow volume
measurements in addition to patient surveys and possibly
interviewing depending on the program, among more tools
for measurement across the board.

6) What are some take-aways and observations that you made in

your clinical rotation experience?
When I was in PR for clinical at CHI, I learned a lot about
community. I was so impressed with the close community with
patients, they all congregated together, encouraged each other,
checked on one another if the other wasn’t there. There were even
two older men that ended up in the same program and later
discovered they went to high school together, now, each morning
they are motivated to go to PR because they bring their coffee for
when they are done and sit in the breakroom and have coffee
together. I was also impressed with the level of education that goes
into utilizing equipment, there are machines I don’t even know how
to use and the patients were teaching me- which is so good to see
because it defies some of the anxiety and fear that surrounds
pulmonary rehab for patients.
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Reflection Telehealth Journaling:

Due Date: 10/16/23
1) What challenges do you believe this group faced having
to create this program on the fly in response to the
pandemic?

2) What are some of the tools they utilize in this

program? Do you feel they are important? Why?

3) How might you measure outcomes for a telehealth

program?

4) What advice do you think was most impactful for

you? How might you use their advice to advocate
change in healthcare?
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LTAC Journaling

1) What LOS must a patient have for CMS in a LTAC?

Generally, patients must have a length of stay greater

than 25 days (Why care settings matter: LTACHS vs.
snfs).

2) How is a LTAC different than a skilled nursing

facility?

In an LTACH, the on site physician visits at least once

per day whereas in an SNF, the physician must visit at
least once every 30 days for the first 90 days of patient’s
stay and then sub specialists are seen of site and
specialists for an LTACH are available at location. The
patient nurse ratio at an LTACH is about 1 to 6 whereas
at an SNF it is 10-40 per nurse. In an LTACH nurses
have experience in critical care and are BLS and ACLS
certified. LTACHs have 24/7 RT in house at every
location whereas it is much more limited in a SNF.
LTACHS also have more diagnostic equipment such as
radiology, telemetry, pharmacy, lab and dialysis on site
whereas SNFs do not. Finally, LTACHs must have
hospital grade ventilation systems and follow CMS
infection control standards whereas SNFs do not (Why
care settings matter: LTACHS vs. snfs).

3) Do some research on the role of the RT in a LTAC.

What are the benefits of having a respiratory therapist?

Just this past July, the AARC (2023) released an

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interview about the role of the RT in LTACHs. The

article addresses whether there is a role and need for
RTs in LTACHs and interviews Dusty Bower, an RRT
who is the CEO of an LTACH in West Virginia. She
oversees the critical care of patients and can make quick
and concise decisions that being an RT for 18 years
prior gave her insight to while practicing as an RT. She
speaks of no day being the same- something an RT is
familiar with. Many patients that are sent to LTACHs
are in need of some sort of respiratory management –
this quantifies even more so the need for RTs in
LTACHs. The article speaks to the diagnostic abilities
RTs have that benefits LTACHs because they do strive
to do as much in house as they can to troubleshoot
effectively. I found it is important for an RT in this
position to understand the process and coverage of care
on a long-term scale. There are many vented and
trached patients for RTs to manage or take management
roles within a LTACH (AARC, 2023).
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Reflection Home Care Journaling:

Due: 10/19/23
Scott Barth Visit 10/12/23
 Volume target therapy in the home (PRVC) can
increase pressure based off lung compliance and
gives a target volume. You set a high- and low-
pressure limit for parameters. (AVAPS) (AVS)
 PS (pressure support is always the pressure
ABOVE PEEP …. PS+EPAP=IPAP
 Passive circuits are preferred in home care
because they compensate for leaks whereas
active circuits do not.
 Mouthpiece Ventilation – saves patient from
getting trach and is used during the day, also
saves from wearing a mask. Can still eat and
talk. They exhale into open air and not a circuit.
 Scott spoke a lot to continue to challenge oneself
in their goals. For myself, I know that I like to
continue to dive further into whatever I am
learning or doing- I don’t want to become
complacent or lukewarm from change and it was
good to hear his perspective reassuring this.

Open Critical Care Resource Tool

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References

Alasiri A, Mohammed V. Healthcare Transformation in Saudi Arabia: An Overview Since the

Launch of Vision 2030. Health Services Insights. 2022;15.
doi:10.1177/11786329221121214

Al-Amoudi S. M. (2017). Health Empowerment and Health Rights in Saudi Arabia. Saudi
medical journal, 38(8), 785–787. https://doi.org/10.15537/smj.2017.8.19832

Almalki, M., Fitzgerald, G., & Clark, M. (2011). Health care system in Saudi Arabia: an
overview. Eastern Mediterranean health journal = La revue de sante de la Mediterranee
orientale = al-Majallah al-sihhiyah li-sharq al-mutawassit, 17(10), 784–793.
https://doi.org/10.26719/2011.17.10.784

Are there opportunities for RTS to advance in LTACHS? Dusty Bower says yes!. AARC. (2023).
https://www.aarc.org/aarc-membership/aarc-membership-benefits/professional-development/
cn23-are-there-opportunities-for-rts-to-advance-in-ltachs-dusty-bower-says-yes/

Bradley, C. (2023). What happens after people lose Medicaid Coverage?. KFF.
https://www.kff.org/medicaid/issue-brief/what-happens-after-people-lose-medicaid-
coverage/

Costs of caring: AHA. American Hospital Association. (2023).

https://www.aha.org/costsofcaring

Employers identify good practices for high-deductible health plans. National Pharmaceutical
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Guidelines for pulmonary rehabilitation programs 5th edition with web resource. Human
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3670964592701
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Holland, A. E., Cox, N. S., Houchen-Wolloff, L., Rochester, C. L., Garvey, C., ZuWallack, R.,
Nici, L., Limberg, T., Lareau, S. C., Yawn, B. P., Galwicki, M., Troosters, T., Steiner, M.,
Casaburi, R., Clini, E., Goldstein, R. S., & Singh, S. J. (2021). Defining modern pulmonary
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Japan’s Healthcare VS the US: Statistics & Cost Comparison. Interac Network. (2023).
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Mollmann, M. (2023). Health Care is a human right-and that means Universal Access. Harvard
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right/

Moneypenny, M. (2020). How to create and design helpful patient education materials. Etactics.
https://etactics.com/blog/creating-patient-education-materials

Palermo, P., & Corrà, U. (2017). Exercise prescriptions for training and rehabilitation in patients
with heart and lung disease. Annals of the American Thoracic Society, 14(Supplement_1).
https://doi.org/10.1513/annalsats.201702-160fr

PBS Frontline "Sick around the World". (2008). YouTube. broadcast.

PBS News Hour "Healthcare: America vs. the World". (2021). YouTube. broadcast.

Sinaiko, A. (2019). Delivery of Patient Centered Care in the U.S. Health Care System: What is
standing in its way?
https://academyhealth.org/sites/default/files/deliverypatientcenteredcare_august2019.pdf

Tolbert, J. and M. Ammula (2023). 10 things to know about the unwinding of the Medicaid
continuous enrollment provision. KFF. https://www.kff.org/medicaid/issue-brief/10-things-
to-know-about-the-unwinding-of-the-medicaid-continuous-enrollment-provision/#seven1.

Why care settings matter: LTACHS vs. snfs. Kindred. (n.d.).

https://www.kindredhospitals.com/resources/blog-ltach-partnerships/2023/03/13/why-care-
settings-matter-ltachs-vs.-snfs

Wood, K. L. (2023, September 29). Exercise testing - pulmonary disorders. Merck Manuals
Professional Edition. https://www.merckmanuals.com/professional/pulmonary-disorders/tests-of-
pulmonary-function-pft/exercise-testing

Wu, T. Y., Majeed, A., & Kuo, K. N. (2010). An overview of the healthcare system in
Taiwan. London journal of primary care, 3(2), 115–119.
https://doi.org/10.1080/17571472.2010.11493315
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