Prior to the 1970s, most medical care was provided in inpatient facilities. The trend in health care has been toward treatment in outpatient centers for reasons of cost containment. However, for those patients who requiring monitoring, treatment or safety concerns based on 24 hour care, inpatient facilities admit and retain overnight patients until discharge. Patients may return home, be transferred to another facility, or death may occur. Types of inpatient facilities include acute-care hospitals, rehabilitation centers, psychiatric hospitals, addiction treatment centers and nursing homes.
Most common are acute care hospitals, which provide immediate to short-term care for patients with life-threatening or potentially life-threatening conditions. Community hospitals are often publicly or privately owned acute care facilities. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) regulates most American hospitals, requiring minimal standards of quality of care and patient safety. Medicare and Medicaid require that hospitals be accredited for payment under their programs.
Nursing homes are the most common type of inpatient facility. While most patients are elderly, nursing homes also admit adult patients of any age with disabilities who are incapable of caring for themselves. Patients with a need for assistance with activities of daily living (ADLs) may be housed separately from more dependent patients to meet their nursing care needs. Nursing home residents are provided occupational therapy, physical therapy and activities aimed at maintaining a level of independence.
Advances in emergency medicine have increased survival rates of victims of major trauma and expanded the need for rehabilitation facilities for recovery from injuries. Neurological rehabilitation of stroke victims at rehab facilities to assist in the return home are now an alternative to nursing homes.
The early history in U.S. health care shows us that the oldest type of inpatient facilities were asylums, a type of psychiatric hospitals. Originally focused on separation and confinement, psychiatric hospitals treat patients with the aim to return them to functioning in the community.
Inpatient drug and alcohol centers may be freestanding or part of a psychiatric unit of a hospital or psychiatric hospital. Addiction treatment centers treat patients through early stages of recovery.
Acute Care Hospitals vs Critical Access Hospitals
In the United States there are a number of forms of the two general types of hospitals. Community hospitals are non-federally funded hospitals but may be non-profit or for profit. They consist of local hospitals that provide short term, general care but may also include specialty hospitals that focus on obstetrics; gynecology; orthopedic; or rehabilitation. Teaching hospitals are usually associated with a university or medical school. Also termed academic hospitals, they have a major role in training health professions. The range of clinical care provided by community and teaching hospitals may be the same.
Community Hospitals– “Community hospitals are defined as all nonfederal, short-term general, and other special hospitals”
Teaching Hospital (Academic Hospital) are usually associated with a university or medical school and have a major role in clinical training of health professionals. The American Medical Association (AMA) requires that teaching hospitals must offer at least one graduate residency program. Most are affiliated with a medical school. Academic medical centers (AMCs) are collaborations between medical schools, health systems and health care professionals.
Public hospitals may or may not be open to the general public. For example, military veterans and Indian services facilities serve only these special groups. State hospitals are generally mental and tuberculosis facilities and local hospitals, such as county and city facilities, are open to the general public.
Private nonprofit hospitals, or voluntary hospitals, may be run by community organizations, private foundations or societies. There are also a large number of church owned facilities which admit the public but are sensitive to the spiritual and dietary needs of the sponsoring denomination. Not-for-profit can be a misconception in that all business must earn a profit. Nonprofits receive a federal tax exemption status and must, therefore, provide service defined as the public good in terms of education or community welfare; and, not distribute any profits to individuals.
Proprietary hospitals are private for-profit hospitals owned by individual, partnership or corporate investors, or stockholders. The trend over the last few years is for large, multihospital chains owned by corporations, although many multihospital chains are operated by nonprofits.
General hospitals provide a large variety of diagnostic, treatment and surgical services to patients with all types of specific medical conditions. Most U.S. hospitals are general hospitals, whether community-based or federally funded.
Specialty hospitals admit only certain populations of patients such as hospitals specializing in mental illness, cardiology or orthopedic surgery. Rehabilitation hospitals for therapeutic services of restoration to maximal functioning and children’s hospitals designed to serve the unique needs of children’s medical conditions are commonly community hospitals.
Rural hospitals are defined as those not located within a county with a metropolitan designation. A metropolitan statistical area (MSA) is defined by the U.S. Census Bureau as having at least one city of 50,000 or more. Elderly and the poor are the majority of patients served in rural hospitals.
Osteopathic Hospitals are facilities that employ an holistic approach with traditional medical practice (allopathic medicine) combined with Complementary and Alternative Medicine (CAM). Osteopathic hospitals are generally community hospitals and are declining in number due to costs and redundancy.
ACUTE CARE HOSPITALS (ACH)
Acute care hospitals provide short term patient care. Length of stay of greater than 25 days is the limit set by Medicare. Acute services include all promotive, preventive, curative, rehabilitative or palliative actions, which is time-sensitive and may involve rapid intervention. The term acute care encompasses a range of clinical health-care functions, including emergency medicine, trauma care, pre-hospital emergency care, acute care surgery, critical care, urgent care and short-term inpatient stabilization
a Treatment of individuals with acute surgical needs, such as life-threatening injuries, acute appendicitis or strangulated hernias.
b Treatment of individuals with acute life- or limb-threatening medical and potentially surgical needs, such as acute myocardial infarctions or acute cerebrovascular accidents, or evaluation of patients with abdominal pain.
c Ambulatory care in a facility delivering medical care outside a hospital emergency department, usually on an unscheduled, walk-in basis. Examples include evaluation of an injured ankle or fever in a child.
d Treatment of individuals with acute needs before delivery of definitive treatment. Examples include administering intravenous fluids to a critically injured patient before transfer to an operating room.
e Care provided in the community until the patient arrives at a formal health-care facility capable of giving definitive care. Examples include delivery of care by ambulance personnel or evaluation of acute health problems by local health-care providers.
f The specialized care of patients whose conditions are life-threatening and who require comprehensive care and constant monitoring, usually in intensive care units. Examples are patients with severe respiratory problems requiring endotracheal intubation and patients with seizures caused by cerebral malaria.
CRITICAL ACCESS HOSPITALS (CAH)
Critical access hospitals are small, rural facilities for limited outpatient services and inpatient hospital services.
This organizational chart displays an overview of what a healthcare organizational structure might look like. It is not intended to be exhaustive but to represent usual divisions and some departments under those divisions. The first box is for management with a link down to each of the displayed divisions. Before it reaches the divisions, there is a dotted line off to the right to medical staff, a quasi-autonomous division that usually reports to the chief medical office or the Chief Executive Officer. The five divisions indicated by boxes linked to management are nursing (with nursing units and nursing education as examples); Clinical Support Services (with physical therapy; radiology and social services as examples); ancillary (with laboratory, transportation, and food services as examples); information (with admitting, medical records, and information technology as examples); and facilities management (with housekeeping, maintenance, and security as examples). The examples are shown in smaller text boxes directly below the division name. Please note that a laboratory could also be listed under clinical support services, since a large part of the department’s function is to run laboratory tests. Many units have functions that cross divisions.
The Chief Executive Officer leads the organization and may report to a board of directors or to a system-level President or Chief Operating Officer. The Chief Operating Officer is responsible for the day-to-operations of the healthcare organization. The Chief Financial Officer manages the fiscal aspects of the organization including the operating budget, contracts, income and expenditures, billing, and compensation. The Chief Medical Officer is usually a physician and is the liaison to the medical staff. He/she also has responsibility for clinical care, quality improvement, and sometimes, graduate medical education. The Chief Information Officer is a relatively new role and has gained prominence with the evolution of technology in medical instrumentation and the increased implementation of Electronic Health Records (EHRs). The Chief Medical Information Officer provides a liaison between clinicians and information technology; this has become a critical role with the implementation of EHRs. The Chief Medical Information Officer often reports to the Chief Information Officer, the Chief Medical Officer, or both.
The medical staff is the governing body of the physicians and sometimes other clinicians. It usually has an elected Chief of Staff. Reporting varies, since the medical staff and hospital administration used to be parallel management structures. The Chief of Staff and the Medical Staff Office manages physician privileges and accreditation issues (sometimes including physician extenders), medical policies, governance of the medical staff, and sometimes continuing medical education including at the department level.
The Nursing Division is typically headed by the Chief Nursing Officer who reports to the Chief Executive Officer. Nursing is responsible for managing and staffing all the nursing units. This includes ambulatory units that may comprise primary care or specialty clinics. There also a growing number of ambulatory surgery or procedure nursing units. Inpatient nursing units are where patients admitted to a hospital are managed and given care. This would usually include Pediatrics; Medicine; Surgery and Obstetrics-Gynecology, but may also include subspecialty units like orthopedics; oncology; or rehabilitation. Critical care units typically include Cardiac Intensive Care; Surgical Intensive Care; Medical Intensive Care; Pediatric Intensive Care; and Neonatal Intensive Care but may include more specialized units in academic or specialized hospitals. Other types of units include the Emergency Department, Labor and Delivery, and Surgery (Operating Rooms and the Post Anesthesia Care Unit). The Nursing Division is also usually responsible for nursing education and professional development training. This sometimes includes training all hospital personnel in areas like Cardio-Pulmonary Resuscitation. In academic hospitals, there may be specific ambulatory or inpatient units that function as research units.
The management structure of Clinical Support Services (also called Allied Health) varies depending on the healthcare organization. Some have a management-level officer who reports directly to the Chief Executive Office; some combine Clinical Support Services and Ancillary Services and divide it into Diagnostic and Therapeutic divisions; and in others, the managers of individual Allied Health departments report directly to the Chief Operating Officer or designate. Clinical Support Service departments support the diagnosis and treatment of patients in specialized areas. Examples of diagnostic Allied Health include Radiology, which is responsible for X-rays, other imaging like Magnetic Resonance Imaging, and Computerized Tomography. Radiology departments also support therapeutic procedures often termed Interventional Radiology. Another would be Cardiology, responsible for diagnostic studies like electrocardiograms, stress tests, and echocardiograms. Cardiology also support more invasive diagnostic and interventional studies like cardiac catheterization. Allied Health Departments that are considered more therapeutic would include physical therapy, which provides care for patients with physical limitations from injuries or disease. Pharmacy is responsible for the acquisition, storage, and dispensing of medication. Social Services is an example of a department that provides patient and family support and counseling, assessment of financial assistance, and discharge planning.
The management structure of Ancillary Services varies depending on the healthcare organization. Some have a management-level officer who reports directly to the Chief Executive Office; some combine Clinical Support Services and Ancillary Services and divide it into Diagnostic and Therapeutic divisions; in others the managers of individual ancillary departments report directly to the Chief Operating Officer or designate. Examples include the laboratory responsible for the collection, analysis, and reporting of laboratory tests. As noted previously, laboratory crosses functions with Clinical Support Services due to the training required to run the analysis of many types of laboratory tests. Another example is transportation, which is responsible for transporting patients within the hospital. This may include transporting patients from admitting to an inpatient unit or from the inpatient unit to a diagnostic service or surgery. Food services is the department charge with preparing and delivering food to patients. They also provide cafeteria services to staff, family members, or visitors. In some hospitals, the food services department reports to the dietetic department.
Facilities is often led by a senior manager who reports to the Chief Operation Officer. The departments are largely involved in managing the facility as a whole; this can include structures and grounds. The Housekeeping department is responsible for cleaning and may include the laundry. Maintenance involves day-to-day repairs and replacement but also includes complex maintenance like electrical, backup generators, and heating and cooling. Security is often included in facilities management and is responsible for security issues such as parking control, identification badges, and securing patient belongings when they are admitted.
All healthcare organizations have certain core functions required to deliver healthcare—management, medical staff, nursing, clinical support, ancillary support, information, and facilities management. How these functions are manifested have to do with the size and type of the organization. A small community health clinic may be administered by the senior physician and an office manager. The medical staff may consist of only a few providers. Nursing staff may include a single nurse and several medical assistants. The medical assistants also provide limited clinical support and Ancillary Services (office laboratory tests or simple diagnostic procedures). The office manager and receptionist may provide much of the registration, billing, referral, and medical records. Facilities management may be a combination of the office staff and contracted cleaning and maintenance. As facilities grow, these functions tend to require more personnel and personnel with additional training and eventually require whole divisions with multiple departments. Community health clinics do not perform complex diagnostic or treatment procedures. Community hospitals and academic hospitals may have similar organizational structure for clinical care.
Inpatient rehabilitation facilities
Inpatient Rehabilitation Facilities
- Inpatient Rehabilitation Facilities (IRFs) are free standing rehabilitation hospitals and rehabilitation units in acute care hospitals. Many patients with conditions like stroke or brain injury, who need an intensive rehabilitation program, are transferred to an inpatient rehabilitation facility. After illness, injury, or surgery, some patients need intensive, inpatient rehabilitative care, such as physical, occupational, or speech therapy.They provide an intensive rehabilitation program and patients who are admitted must be able to tolerate three hours of intense rehabilitation services per day.
To qualify as an IRF, a facility must meet Medicare’s conditions of participation for acute care hospitals and must be primarily focused on treating conditions that typically require intensive rehabilitation, among other requirements. IRFs can be freestanding facilities or specialized units within acute care hospitals. To qualify for a covered IRF stay, a beneficiary must be able to tolerate and benefit from intensive therapy and must have a condition that requires frequent and face to-face supervision by a rehabilitation physician. Other patient admission criteria also apply. In 2013, Medicare spent $6.8 billion on IRF care provided in about 1,160 IRFs nationwide. About 338,000 beneficiaries had more than 373,000 IRF stays. On average, Medicare accounts for about 61 percent of IRFs’ discharges.
- To qualify as an IRF for Medicare payment, facilities must meet the Medicare IRF classification criteria. The first criterion is that providers must meet the Medicare conditions of participation for acute care hospitals. They must also:
• have a preadmission screening process to determine that each prospective patient is likely to benefit significantly from an intensive inpatient rehabilitation program;
• ensure that the patient receives close medical supervision and provide—through qualified personnel—rehabilitation nursing, physical therapy and occupational therapy, and, as needed, speech– language pathology and psychological (including neuropsychological) services, social services, and orthotic and prosthetic devices;
• have a medical director of rehabilitation with training or experience in rehabilitation who provides services in the facility on a full-time basis for freestanding IRFs or at least 20 hours per week for hospital-based IRF units;
• use a coordinated interdisciplinary team approach led by a rehabilitation physician that includes a rehabilitation nurse, a social worker or case manager, and a licensed therapist from each therapy discipline involved in the patient’s treatment; and
• meet the compliance threshold that requires that no less than 60 percent of all patients admitted to an IRF have as a primary diagnosis or comorbidity at least 1 of 13 conditions specified by the Centers for Medicare & Medicaid Services (CMS). The intent of the compliance threshold is to distinguish IRFs from acute care hospitals. If an IRF does not meet the compliance threshold, Medicare pays for all its cases on the basis of the inpatient hospital prospective payment system rather than the IRF PPS.
Medicare facility requirements for IRFs.
Federally Funded Health Care Institutions
Federally Funded Health Care Institutions
There are three main federally funded healthcare institutions in the United States: the Veterans Health Administration, Military Medicine, and the Indian Health Services.
Veterans Health Administration (VA)
The Veterans Health Administration is the largest integrated health care system in the United States, providing care at 1,233 health care facilities, including 168 VA Medical Centers and 1,053 outpatient sites of care of varying complexity (VHA outpatient clinics), serving more than 8.9 million Veterans each year. The VA also includes community living centers; Vet Centers (for outreach); and Domiciliaries to care with patients with long-term medical conditions in a home-like atmosphere. As with any integrated health system, the VA provides primary, secondary, and tertiary care.
VHA Medical Centers provide a wide range of services including traditional hospital-based services such as surgery, critical care, mental health, orthopedics, pharmacy, radiology and physical therapy.
In addition, most medical centers offer additional medical and surgical specialty services including audiology & speech pathology, dermatology, dental, geriatrics, neurology, oncology, podiatry, prosthetics, urology, and vision care. Some medical centers also offer advanced services such as organ transplants and plastic surgery.
Available at every medical center, Patient Advocates are highly trained professionals who can help resolve your concerns about any aspect of your health care experience, particularly those concerns that cannot be resolved at the point of care. Patient Advocates listen to any questions, problems, or special needs you have and refer your concerns to the appropriate Medical Center staff for resolution.
VA Medical Centers
The Veterans Health Administration is home to the United States’ largest integrated health care system consisting of 152 medical centers. The VA health care system has grown from 54 hospitals in 1930, to include 152 hospitals, 800 community-based outpatient clinics, 126 nursing home care units and 35 domiciliaries.
Military Health System
The Military Health System is part of the US Department of Defense. It provides services to service members, retirees, and their families. Each branch of the armed forces has its own network of hospitals and healthcare facilities. TRICARE is a healthcare program that ensures care worldwide. This includes military facilities and is supplemented by civilian healthcare providers, organizations, and pharmacies
Indian Health Service
The Indian Health Service (IHS), an agency within the Department of Health and Human Services, is responsible for providing federal health services to American Indians and Alaska Natives. The provision of health services to members of federally-recognized Tribes grew out of the special government-to-government relationship between the federal government and Indian Tribes. This relationship, established in 1787, is based on Article I, Section 8 of the Constitution, and has been given form and substance by numerous treaties, laws, Supreme Court decisions, and Executive Orders. The IHS is the principal federal health care provider and health advocate for Indian people, and its goal is to raise their health status to the highest possible level. The main goals are to provide access to care and to reduce health disparities. The IHS provides a comprehensive health service delivery system for American Indians and Alaska Natives.
Organization of inpatient care facilities
The American Hospital Association (AHA) defines a hospital as an institution with at least 6 beds who deliver diagnostic and therapeutic patient services. Beginning with the almshouses and asylums of social welfare in the eighteenth century, hospitals later became community hospitals supported by affluent donors. Teaching hospitals evolved to serve the needs of all patients and make profits. More recently, physician owned hospitals emerged and then university centers of medical research. In the past few decades, the arrival of managed care systems and integrated delivery systems inpatient facilities are the treatment centers that provide round the clock overnight care. Specializing in acute care and surgical services, hospitals serve large populations and provide a wide range of medical services. With the advances in medical science, inpatient facilities are in need of a growing number of care providers.
Most American hospitals are community hospitals that are private, nonprofit facilities regulated by licensure from The Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The organization of hospitals and inpatient facilities can best be observed in an organizational chart. Describe the organization of your local health facility to become familiar with resources in your community.