Health Care Delivery System/Exam 2

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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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