quality of care — a measure of the degree to which delivered health services meet established professional standards and judgments of value to the consumer. Quality may also be seen as the degree to which actions taken or not taken maximize the probability of beneficial health outcomes and minimize risk and other untoward outcomes, given the existing state of medical science and art. Quality is frequently described as having three dimensions: quality of input resources (e.g., certification and training of providers); quality of service delivery (e.g., the use of appropriate procedures for a given condition); and quality of outcomes (e.g., actual improvement in condition or reduction of harmful effects).
rate review — review by a government or private agency of a hospital's budget and financial data performed for the purpose of determining the reasonableness of the hospital’s rates and evaluating proposed rate increases.
re-entry population — juveniles and adults who have been released from incarceration. People re-entering their communities face both personal and societal barriers to finding housing, employment and social support, which are key determinants of health. See also incarcerated and formerly incarcerated individuals.
referral — the process of sending a patient from one practitioner to another for health care services. Health plans may require that designated primary care providers authorize referrals for coverage of specialty services.
rehabilitation — the combined and coordinated use of medical, social, educational and vocational measures for training or retraining individuals disabled by disease or injury to reach the highest possible level of functional ability. Several different types of rehabilitation are distinguished: vocational, social, psychological, medical and educational.
reimbursement — the process by which health care providers receive payment for their services. Because of the nature of the health care environment, providers are often reimbursed by third parties who insure and represent patients.
report card — a report presented on the quality of health services designed to inform patients and health care purchasers of a practitioner’s or organization’s performance.
remaining uninsured — people who, after the implementation of the Affordable Care Act, still do not have health insurance. These include individuals who are not eligible for insurance due to immigration status and those who face barriers to enrollment and need assistance navigating the enrollment process.
resilient youth — young people, ages 14 to 26, who are in, or have exited, the juvenile or adult criminal justice systems; are currently or were formerly in foster care; or are/were homeless. See also at-risk youth.
responsive grantmaking — used to describe the philanthropic strategy of responding to ideas that originate in communities, as opposed to ideas that originate in foundation offices.
returning citizens — sometimes used by Cal Wellness to describe individuals returning to their communities after a period of incarceration.
risk — responsibility for paying for or otherwise providing a level of health care services based on an unpredictable need for these services.
risk adjustment — a process by which premium dollars are shifted from a plan with relatively healthy enrollees to another with sicker members. It is intended to minimize any financial incentives health plans may have to select healthier than average enrollees. In this process, health plans that attract higher risk providers and members would be compensated for any differences in the proportion of their members that require higher levels of care compared to other plans.
risk selection — occurrence when a disproportionate share of high or low users of care join a health insurance plan.
risk sharing — the distribution of financial risk among parties furnishing a service. For example, if a hospital and a group of physicians from a corporation provide health care at a fixed price, a risk-sharing arrangement would entail both the hospital and the group being held liable if expenses exceed revenues.
rural health clinic — a public or private hospital, clinic or physician designated by the federal government as in compliance with the Rural Health Clinics Act (Public Law 95-210). The practice must be located in a medically underserved area or a health professions shortage area and use a physician assistant and/or nurse practitioners to deliver services. A rural health clinic must be licensed by the state and provide preventive services.
rural health network — refers to any of a variety of organizational arrangements to link rural health care providers in a common purpose.
safety-net organization — any organization that provides health care services to people who are not able to afford them. These can include, but are not limited to, community clinics, clinic consortia, hospitals, mobile clinics and dental clinics.
screening — the use of quick procedures to differentiate apparently well persons who have a disease or a high risk of disease from those who probably do not have, or will not contract, a disease. It is used to identify high-risk individuals for more definitive study or follow-up. Multiple screening (or multiphasic screening) is the combination of a battery of screening tests for various diseases performed by technicians under medical direction and applied to large groups of apparently well persons.
secondary care — services provided by medical specialists who generally do not have first contact with patients (e.g., cardiologists, urologists and dermatologists). In the U.S., however, there has been a trend toward self-referral by patients for these services, rather than referral by primary care providers. This is quite different from the practice in England, for example, where all patients must first seek care from primary care providers and are then referred to secondary and/or tertiary providers, as needed.
secondary opinions — in cases involving nonemergency or elective surgical procedures, the practice of seeking judgment of another physician in order to eliminate unnecessary surgery and contain the cost of medical care.
secondary prevention — early diagnosis, treatment and follow-up for patients who have already contracted diseases. Secondary prevention activities start with the assumption that illness is already present and that primary prevention was not successful. The goal is to diminish the impact of disease or illness through early detection, diagnosis and treatment.
self-funding/self-insurance — an arrangement where an employer or group of employers sets aside funds to cover the cost of health benefits for their employees. Benefits may be administered by the employer(s) or handled through an administrative service only agreement with an insurance carrier or third-party administrator.
service period — period of employment that may be required before an employee is eligible to participate in an employer-sponsored health plan, most commonly one to three months.
severity of illness — a risk prediction system to correlate the "seriousness" of a disease in a particular patient with the statistically "expected" outcome (e.g., mortality, morbidity or efficiency of care). Most effectively, severity is measured at, or soon after, admission, but before therapy is initiated, giving a measure of pretreatment risk.
sexually healthy adolescent — a sexually healthy adolescent, as agreed upon by more than 50 national health organizations, has the information needed to make responsible decisions about sexual behavior, an understanding of sexual development and feelings, an ability to maintain personal boundaries and an awareness of possible consequences of his or her decisions.
shared services — the coordinated, or otherwise explicitly agreed upon, sharing of responsibility for provision of medical or nonmedical services on the part of two or more otherwise independent hospitals or other health programs. The sharing of medical services might include an agreement in which one hospital provides all pediatric care needed in a community and no obstetrical services while another provides obstetrics and no pediatrics. Examples of shared nonmedical services would include joint laundry or dietary services for two or more nursing homes.
skilled nursing facility — a nursing care facility participating in the Medicaid and Medicare programs that meets specified requirements for services, staffing and safety.
skills training — an approach that seeks to train youths in the personal and social skills needed to resist pressures to use violence or engage in other behaviors that put their health at risk.
small business health insurance options program — a section of a health insurance exchange where employers can purchase health insurance for employees and apply for tax breaks.
social capital — the degree of social cohesion that exists in communities, such as the processes among people that establish networks, norms and social trust, and facilitate coordination and cooperation for mutual benefit. The stronger these networks and bonds, the more likely it is that members of a community will cooperate for mutual benefit. In this way, social capital creates health and may enhance the benefits of investments for health.
social determinants of health — the conditions in which people are born, grow, live, work and age, including the social environment, physical environment, health services, and structural and societal factors. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities.
social environment — encompasses the level of interaction and relationships among individuals in the community. Relationships and interaction with others provide: models for lifestyle change; controls and constraints on behavior; access to information; and a sense of meaning and purpose to life that can help make healthy lifestyle changes seem more attainable. Projects to improve the social environment focus on reinforcing social networks and social support within the community and developing the material resources available to the community. Activities can include neighborhood health fairs; community-sponsored sports programs; and exercise, peer support and self-help groups.
social support — the assistance available to individuals and groups from within communities that can provide a buffer against adverse life events and living conditions, and can provide positive resources for enhancing the quality of life. Social support may include emotional support, information sharing, and the provision of material resources and services. Social support is now widely recognized as an important determinant of health and an essential element of social capital. Natural and professional sources of social support include families, tribes, friends, neighbors, parishioners, classmates, coworkers, merchants, and health and social services providers. Vehicles of support can include community affiliations, community activities, religious activities and organized self-help groups.
solo practice — lawful practice of a health occupation as a self-employed individual. Solo practice is by definition a private practice but is not necessarily a general practice or fee-for-service practice. Solo practitioners may be paid by capitation, although fee-for-service is more common. Solo practice is common among physicians, dentists, podiatrists, optometrists and pharmacists.
specialist — a physician, dentist or other health professional who is specially trained in a certain branch of medicine or dentistry related to specific services or procedures (e.g., surgery, radiology and pathology); certain age categories of patients (e.g., geriatrics); certain body systems (e.g., dermatology, orthopedics and cardiology); or certain types of diseases (e.g., allergies and periodontal diseases). Specialists usually have advanced education and training related to their specialties.
supplemental security income — a federal cash assistance program for low-income aged, blind and disabled individuals established by Title XVI of the Social Security Act. States may use supplemental security income limits to establish Medicaid eligibility.
supportive environments for health — environments that offer people protection from threats to health and enable them to expand their capabilities and develop self-reliance in health. Supportive environments for health encompass local communities; homes; places where people work and play, including access to resources for health; and opportunities for empowerment. (See also chemical environment, physical environment and social environment.)
supportive housing — affordable housing linked with social services tailored to the needs of the population being housed with the goal of helping them increase their coping and life management skills and gain access to community-based resources to resolve crises in their lives. Examples of services include drug treatment, life skills classes, counseling, job training, assistance with accessing income supports and referrals for health care.
Temporary Assistance for Needy Families — federal government program that provides cash assistance to low-income families, commonly referred to as the federal welfare program.
technology assessment — a comprehensive form of policy research that examines the technical, economic and social consequences of technological applications. It is especially concerned with unintended, indirect or delayed social impacts. In health policy, the term has come to mean any form of policy analysis concerned with medical technology, especially the evaluation of efficacy and safety.
telemedicine — the use of telecommunications (e.g., wire, radio, optical or electromagnetic channels transmitting voice, data and video) to facilitate medical diagnoses, patient care and/or distance learning.
tertiary care — services provided by highly specialized providers (e.g., neurologists, neurosurgeons, thoracic surgeons and intensive care units). Such services frequently require highly sophisticated equipment and support facilities. The development of these services has largely been a function of diagnostic and therapeutic advances attained through basic and clinical biomedical research.
tertiary prevention — prevention activities that focus on the individual after a disease or illness has manifested itself. The goal is to reduce long-term effects and help individuals better cope with symptoms.
third-party payer — any organization, public or private, that pays or insures health or medical expenses on behalf of beneficiaries or recipients. An individual pays a premium for such coverage in all private and in some public programs; the payer organization then pays bills on the individual's behalf. In such arrangements, the individual receiving the service is the first party, the individual or institution providing the service is the second party, and the organization paying for the service is third party.
transition-age youth — young people between the ages of 16 and 24 who are in transition out of state custody or foster care. At the age of 18, these young people are considered adults and no longer receive support from the state, even though they face a number of barriers to successful, independent living.