What is the Health Care Delivery System?
A mechanism for providing services that meet the health-related needs of individuals.
Goal: To decrease the risk to a client (individual, family, or community) of disease or dysfunction.
Approach: General health promotion. Protection against specific illnesses.
Goal: To alleviate disease and prevent further disability.
Approach: Early detection and intervention.
Goal: To minimize disability associated with chronic or irreversible conditions.
Approach: Restorative and rehabilitative activities to attain optimal level of functioning.
The U.S. System
Health care services are delivered and financed by three sectors:
The public (official, voluntary, and nonprofit agencies)
Private (hospitals, extended-care facilities, hospices, schools, etc.)
Health Care Agencies
Public health services
Routine health screening
Diagnosis and treatment
Ambulatory care centers
Diagnostic treatment facilities
Occupational health clinics
Run by companies for employees
Health promotion activities
Acute inpatient services
Outpatient and ambulatory care
Variation of inpatient care
Technically complex treatme
Extended care facilities (formerly called nursing homes)
Assisted, skilled, extended care facilities
Retirement and assisted-living centers
For clients unable to stay at home, but do not require hospital or nursing home
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
Services for rural residents
Diverse reimbursement base
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.
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
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
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.
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.
Inclusive rate established for each episode of hospitalization based on:
Presence or absence of surgery
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
Factors Influencing Health Care
Many factors influence an individuals ability to access the health care system:
Inadequate or cost of insurance
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
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.
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
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).
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
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
Maintenance of hospital policy
Predictability of nursing and medical goals
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