The Health Care Delivery System and Nursing Roles- Theories and Concepts

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Healthy People Objective

What person does the person need and want?
Who can best provide these services?
Where is the most efficient and effective place to receive these services?
How will these services affect the quality and cost of care, as well as patient and health care worker satisfaction?

Types of Health Care Services

Health Promotion
Illness Prevention
Diagnosis and Treatment
Rehabilitation and Long-Term Care

Health Promotion

Motivated by the desire to increase well-being and actualize health potential
Expands positive potential for health
Seeks to prevent development of risk factors
Focuses on lifestyle changes
Health teaching (Prenatal classes)
Exercise classes
Nutrition instruction

Illness Prevention

Services initiated after risk factors are identified (different than health promotion)
Activities aimed at diminishing the likelihood that functions become impaired
Identified of risk factors
Monitoring health status
Require active participation

Diagnosis and Treatment

Services aimed at determining the presence of disease
Health screening activities
Mammography
Various blood tests
Vision and hearing screening
Widely available technologies: CT Scans, Ultrasound, Laparoscopic Instruments

Rehabilitation and Lonterm Care

Rehabilitation - Restorative in focus with a goal of independence to the fullest possible level of function
Long-term care - Services based on the level of independence and health care needs required
Rehab programs often leave patients with less than full functioning

Disease Management

Services deal with chronic conditions
Focuses on helping patients understand and manage their chronic conditions
Process: phone calls, coaching and education, symptom prevention and management, and collaborations with other providers

Classification of Health Care Agencies

Governmental or Voluntary
For-Profit and Not-for-profit
Types of services offered
1, 2, 3

Governmental Agencies

Funded through taxes
Local
State
Federal
Examples: Federal agencies: NIH, DHHS, OSHA, CDC, and Centers for Medicare and Medicaid

Voluntary Agencies

Private organization
Supported through donations
Not-for-profit (most)
Staffed by volunteers

For-Profit and Not-For-Profit Agencies

Differentiated by use of profit

For-Profit - distributed to shareholders or partners
Not-for-profit - used to benefit the agency and its mission

Levels of Health Care Services

Primary Care

First contact, or entry into the system
Health maintenance
Emergency care
Treatment of temporary health problems that do not require hospitalization

Organizational Structure of Health Care Agencies

How an organization is organized to accomplish its mission
Board of Directors, Chief Executive Officer, Chief Nurse Executive (Nursing Staff)
Health Care Team: Physicians, Physician Assistants, Dieticians, Pharmacists, Technologists, Respiratory Therapists, Social Workers, Administrative support personnel, educator, Manager, Patient Advocate, Entrepreneur, Researcher, Collaborator

Responsibilities of Nurse Managers and Nurse Executives

Nurse Managers: Direct supervision of assigned staff: manage recruitment, evaluate quality of care, budget for assigned areas
Nurse Executives: partner with other disciplines and leaders, acquire resources for function and leadership, lead and direct patient care, accountable for continuous quality improvement, budget for entire nursing department

Types of Nursing Care Delivery Systems

Functional Nursing: work side by side each performing a task
Team Nursing: a team leader, LPN, and one or more CNA's
Team Leader: ultimately responsible and delegates (assigns responsibility for certain patients to each team member)
RN oversees all care for a particular shift
Primary Care Nursing: identified nurse for every patient: each nurse is responsible for the care during the patient stay

Managed Care Organizations

Managed care and cost containment- 1990's largest Health Insurance US
Health maintenance organization (HMO)
largest Health Insurance U.S.
Preferred provider organization (PPO)
Point-of-service organization (POS)
Physician hospital organization (PHO)

HMO's

HMO's: defined group of people receive service for a predetermined fixed fee (called capitation: same amount paid to provider whether you receive services or not)
PPO's: contracts with independent providers
Point of Service Organization: may choose to stay within the defined network or may go outside and pay more
Physician Hospital Organization: group of its medical staff purpose of contracting with managed care organizations

Nurse's Role and Health Care Response in Managed Care

Advanced Nurse Practitioners
Forced the health care organizations to restructure and be efficient
Patient centered care: placing the patient in the center; design services to attain desired patient outcomes
Decentralization: empowers staff and exercise own judgment
Cross functional teams and cross-trained

Assessing Quality

Accreditation
-Joint Commission on the Accreditation of Health Care Organizations(JCAHO)
Continuous Quality Improvement (CQI)

Impact of Managed Care

Health Maintenance Organizations (HMO)
Quality of care- concern decrease
Care decisions + business interests
Limits of types of services offered
Limits on physicians and medical options
Advise on treatment option
Give MD bonus
Conflict b/t best interest patient and own ecomomics
Concern from medicine, nursing, consumers and congress

Financing Health Care

Supply and Demand: two parts: suppliers and patients

Health Care as a Right or Priviledge

Determined by the individuals ability to pay
Federal government has taken steps to assure certain groups have access to health care (Medicare: Tile XV111 of Social Security Act; Medicaid Title X1X of Social Security Act)

Other Methods of Payment

Out of Pocket
Private Insurance
Worker's Compensation

Health Care Challenges

Rising cost of care
Rise of individuals without health insurance
Limits on choice and access
Costs of prescription drugs
Malpractice and impact on care

Health Care Reform and Universal (Minimum Benefits) Access

Obama Initiative
Passed in the House; now to Senate
Cover pre existing conditions
Should there be a public health care program financed and directed by the Federal Government?
Mechanisms for controlling costs
Affect on Nursing?

Health Care Delivery

Needed
Healthy People 2010: individuals have to be a part in prevention
Is it a right or a privilege?
Different types of Health Care Reimbursement
48 million people without health care
Nurses use a variety of roles

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