Health Care Delivery System/Exam 2
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30 terms
Terms | Definitions |
|---|---|
 What is the Health Care Delivery System? | A mechanism for providing services that meet the health-related needs of individuals. |
| Primary Care | Goal: To decrease the risk to a client (individual, family, or community) of disease or dysfunction. Approach: General health promotion. Protection against specific illnesses. Health Promotion Illness Prevention |
| Secondary Care | Goal: To alleviate disease and prevent further disability. Approach: Early detection and intervention. Diagnosis Early detection Treatment |
| Tertiary Care | Goal: To minimize disability associated with chronic or irreversible conditions. Approach: Restorative and rehabilitative activities to attain optimal level of functioning. Rehabilitation Health restoration Palliative care |
| The U.S. System | Health care services are delivered and financed by three sectors: The public (official, voluntary, and nonprofit agencies) Public/private Private (hospitals, extended-care facilities, hospices, schools, etc.) |
| Health Care Agencies | Government agencies Public health services Physicians' offices Primary care Routine health screening Diagnosis and treatment Ambulatory care centers Diagnostic treatment facilities Minor surgery Occupational health clinics Run by companies for employees Health promotion activities Hospitals Acute inpatient services Outpatient and ambulatory care Emergency department Hospice care Subacute care Variation of inpatient care Technically complex treatme Extended care facilities (formerly called nursing homes) Independent living Assisted, skilled, extended care facilities Rehabilitation Custodial care Retirement and assisted-living centers For clients unable to stay at home, but do not require hospital or nursing home Rehabilitation centers Restore or recuperate health Drug and alcohol Home health care agencies Education to clients and families Care to acute, chronic, or terminally ill Rural care hospitals Federal funding Services for rural residents |
| Reimbursement Methods | Diverse reimbursement base Private funding Public funding Fee-for-service method Recipient pays the provider for health care services when they are performed |
| Private Insurance Model | Basis of U.S. system Individual pays monthly premiums for coverage and receives access on an as needed basis Costs of premiums limit access for many |
| Managed Care Model | Developed to provide coordinated care with an emphasis on prevention A system of providing and monitoring care wherein access, cost, and quality are controlled before or during delivery of service |
| Health Maintenance Organizations | Single point of entry. Entry into the health plan through a point designated by the plan. Emphasizes wellness. Fee is preset and prepaid Provide services to a group of enrolled persons |
| Preferred Provider Organizations | Allow individuals to access health care from within an organization of providers. Fees are preset and prepaid Networks of providers that give discounts to sponsoring organization Members are not mandated to select a specific primary care provider but must use a provider in the network |
| Government Plans | Third-party payer beginning in 1965 Centers for Medicare and Medicaid Services (CMS) is federal agency that regulates Medicare and Medicaid expenditures Created diagnosis-related groups (DRGs) to curtail spending |
| Medicare | part A includes post-hospital extended care and home health benefits. workers with permanent disabilities and their dependents who are eligible for disability insurance under Social Security. Also added extremely expensive hospital care, catastrophic care and expensive drugs. -part B is a voluntary and provides partial coverage of outpatient and physician services to people eligible for part A. -part D is the voluntary prescription drug plan begun 1996. -does not cover dental care, dentures, eyeglasses, hearing aids. |
| Medicaid | State and federal venture for the 'medically indigent for Social security act. medicaid is a federal public assistance program paid out of general taxes to people who require financial assistance, such as people with low income. Paid by federal and state government. |
| State Children's Health Insurance Program | -established 1997. state and federal collaborative to provide insurance coverage for poor and working-class children. coverage includes visits to primary health care providers, prescription medicines, and hospitalization. |
| DRGs | Inclusive rate established for each episode of hospitalization based on: Client's age Diagnosis Presence or absence of surgery Co-morbidity |
| HACs | A serious preventable adverse event that is a hospital-acquired condition (HAC) Examples: Falls, severe pressure ulcers, surgical site infections Medicare Modernization Act and Deficit Reduction Act of 2005 permits the CMS to reduce or refuse reimbursement to hospitals for HAC |
| Factors Influencing Health Care | What is Driving Health Care Costs? Intensity of services Prescription drugs and technology Aging of the population Administrative costs |
| Factors Influencing Health Care | Access Issues Many factors influence an individuals ability to access the health care system: Inadequate or cost of insurance Cultural barriers Limited access to ancillary services (e.g. child care, transportation) Certain preexisting conditions making it difficult to obtain insurance Shortage of providers in rural or inner city areas |
| Factors Influencing Health Care | Quality Issues Many factors influence the quality of care individuals receive: he litigious environment and response toward defensive practice (e.g. ordering all possible tests). The widely held American belief that more is better. Lack of access to and continuity of services result in subsequent misuse of acute services. |
| Agency for Healthcare Research and Quality (AHRQ) | Federal agency that is home to research centers that specialize in major areas of health care research such as quality improvement and patient safety, outcomes and effectiveness of care, clinical practice and technology assessment, and health care organization and delivery systems. |
| Challenges | The U.S. Healthcare system faces some serious challenges: Public's disillusionment with providers Public's loss of control over health care decisions Changes in practice settings Ethical issues Health care needs of vulnerable populations |
| Nursing's Vision for the Future | To provide health care services that emphasize PREVENTION and PRIMARY HEALTH CARE for clients, thereby helping to reduce costs and increase the quality of health care |
| Primary Health Care | essential health care; based on practical, scientifically sound, and socially acceptable method and technology; universally accessible to all in the community through their full participation; at an affordable cost; and geared toward self-reliance and self-determination (WHO & Unicef, 1978, p. 35). |
| Primary Care | integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community (IOM, 1994, p. 5) |
| Community-based Nursing (CBN) | Directed toward specific individuals Care is not confined to one practice setting, extending beyond institutional boundaries Involves a network of nursing services, for example Ambulatory centers Home health School health Hospice |
| Community-based Health Care | Primary health care system Services provided within context of peoples' lives Care is directed toward a specific geographical group |
| Traditional Acute Care Settings: Nursing Role Benefits | Predictable routine Maintenance of hospital policy Predictability of nursing and medical goals Resource availability Collegial collaboration and consultation Controlled client adherence with plan of care; the client takes medicine and treatment on time Standardization of care |
| Community-based Nursing: Client Benefits | Familiar and comfortable environment Routine that is less determined by the nurse or health profession Diverse resources, including friends, family, pets, available for support and comfort Autonomy and choice in health decisions |
| Effective CBHC Systems | Provides easy access to care Is flexible in responding to needs Promotes communication among agencies Support family caregivers Is affordable |
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