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Definitions

Making the right health care decisions is imperative to the well-being of our residents and their families. In the confusing health care world, new terms can often overwhelm residents who simply don’t understand health care’s unique terminology. Listed below are many of the terms you’ll hear when discussing you or your loved one’s care as a resident at our care community. It’s our hope that this knowledge will help you, your family and our dedicated staff communicate effectively when discussing your stay with us.

ADLs – Activities of daily living.

Ambulatory Care – Outpatient medical services (not provided in a hospital).

Assisted Living – A special combination of housing and personalized supportive services, designed to respond to an individual’s needs. The needs can range from socialization to activities of daily living to medication administration or special diets.

CMS – The federal agency responsible for Medicaid and Medicare; part of the U.S. Department of Health and Human Services/HHS.

Dual-Eligibles – People who are eligible for both Medicaid and Medicare.

DME/Durable Medical Equipment – Necessary medical equipment that is not disposable; for example, wheelchairs, walkers, ventilators, commodes.

Enrollee – Person (consumer) who is covered under a health insurance plan, whether fee-for-service or managed care.

Formulary – List of approved prescription medications which health plan pays for.

Gatekeeper – Person, usually a primary care physician, designated by health plan to decide what services will be provided and paid for; approves all referrals, sometimes coordinates care.

HMO/Health Maintenance Organization – Health plan that requires its enrollees to use only certain health providers and hospitals, usually those within its own network.

MCO/Managed Care Organization – Health organization, whether for-profit or not-for-profit, that finances and delivers health care using a specific provider network and specific services and products.

Medicaid – Federal program (Title XIX of the Social Security Act) that pays for health services for certain categories of people who are poor, elderly, blind, disabled, or who are enrolled in certain programs, including Medicaid Waivers. Includes children whose families receive assistance. Is financed with federal and state funds, amount varying by state.

Medicare – Title XX of the Social Security Act which pays for health care for the elderly and adults who are disabled.

Medical Necessity – Legal term used to determine eligibility for health benefits and services. It describes services that are consistent with a diagnosis, meet standards of good medical practice.

Occupational Therapy – Therapists seek to optimize the patients’ quality of life by improving their ability to perform activities of daily living, or ADLs. ADLs include tasks such as eating, bathing, dressing, grooming, toileting, transferring and home management responsibilities.

PHO/Physician Hospital Organization – Organization that includes hospitals and physicians contracting with one or more HMO, insurance plan, or directly with employers to provide medical services.

PHP/Prepaid Health Plan – Health organization that receives prepaid capitation payments for a select set of benefits; for example, physician services or lab tests.

Physical Therapy – Therapists seek to improve the patients’ quality of life by increasing mobility, decreasing pain, improving balance, enhancing strength and reducing joint contractures.

POS/Point of Service Plan – Health plan whose members can choose their services when they need them, either in the HMO or from a provider outside the HMO at some cost to the member. Or a plan in which the primary provider directs services and referrals.

PPO/Preferred Provider Organization – Managed care organization (MCO) that contracts with a network of providers who deliver services for set fees, usually at a discount to the MCO. PPOs usually sell to insurers and employers and do not assume insurance risk.

Quality Assurance – Monitoring and improving health care, either an individual plan or broad health systems review, in a consistent and organized way.

Rehabilitation – To restore to good health or useful life, as through therapy and education.

Reinsurance – Insurance purchased by a health plan to protect against extremely high medical costs, either for specific groups or individuals.

SNF (Skilled Nursing Facility)/Skilled Care Community – Where skilled nursing and related services are provided to residents; a nursing home.

Speech Therapy (speech pathology) – Speech therapy helps patients to better understand what is being communicated to them and to regain their verbal communication abilities. Speech therapy also assists in retraining patients to read and write. Additionally, in some cases, speech therapy can help patients whose communication ability may appear to be intact but the patient’s cognitive and linguistic functions are impaired.