1 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 03 Public Health and Primary Health Care Systems and Health Care Transformation

2 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Objectives 1. Describe the trends that are influencing the evolution of the health care system in the early decades of the twenty-first century. 2. Define public health and primary health care, and explain the nursing roles in each. 3. Evaluate the effectiveness of the United States primary health care system to meet the established goals of Alma Ata as the basis for primary health care.

3 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Objectives, Cont’d 4. Describe the current public health system in the United States. 5. Compare and contrast the responsibilities of the federal, state, and local public health systems.

4 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Definitions (Box 3-1)  Disease prevention  Disparities  Electronic health record  Globalization  Health

5 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Definitions, Cont’d (Box 3-1)  Health promotion  Institute of Medicine  Primary care  Primary health care  Public health

6 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Current Health Care Systems in the United States  Indicators that continue to cause disparities in the United States’ health care system:  Cost  Access  Quality

7 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Cost  2008 “Great Recession”  Weakening of national and global economy  Loss of 7 million jobs in the United States  National health spending expected to grow 6.1% per year, reaching $4.5 trillion by 2019 Per capita spending increasing from $8046 in 2009 to $13,387 in 2018  Increases in public spending  Decreases in private spending  By 2012, expect public payment for health care services will account for more than 50% of total health care purchases in the U.S.

8 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Cost, Cont’d

9 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Cost, Cont’d  Aging Baby Boomer population  Will increase Medicare expenditures  Medicaid recipients can be expected to decline as jobs are added to the economy.  Percentage of workers covered by employer- sponsored insurance should rise.  Premiums increase  Higher co-pay and deductible expenses  Costs will rise  Rise in percentage of uninsured

10 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Access  Rise in uninsured people to 46.3 million in 2008  Government programs play significant role in meeting the needs of the uninsured  Increasing demands leave some states struggling with budget  Strong relationship between health insurance coverage and access to health care services  Groups who face greatest barriers to access:  Poor  Minority group members  Non-English speakers

11 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Access, Cont’d  Medically underserved  56 million in the United States lack adequate access to primary health care (2007)  Safety net  Community health centers  American Recovery and Reinvestment Act of 2009 (ARRA)

12 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. United States Health Spending

13 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Life Expectancy

14 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Quality  To Err is Human: Building a Safer Health System (IOM, 2000)  98,000 deaths a year attributed to preventable medical errors 7,000 of which are due to preventable medication errors  Keeping Patients Safe: Transforming the Work Environment of Nurses (IOM, 2003)  Long work hours pose most serious threat  Cultivating a culture of safety  Sentinel events reporting  Hospital Compare

15 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Trends Affecting the Health Care System Demographics Technology Global Influences

16 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Demographics  Aging Baby Boomer generation  Cost of Medicare expected to rise  Rise in foreign-born population  Lack of diversity in health care workforce  Pew Commission

17 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Technology  Examples:  Telehealth  Electronic medical records  Personal Health Record (PHR)  Health Information Exchanges (HIEs)  Benefits:  Cost-effective  Improved care  Reduce medical errors  Pitfalls:  Concerns about privacy and security  Unclear reimbursement for services provided at distance

18 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Global Influences  Globalization  Infectious disease outbreaks  World Health Organization (WHO)  International Health Regulations (2005)

19 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Organization of the Health Care System Primary Health Care System Primary Care Public Health System The Federal System The State System The Local System

20 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Primary Care Versus Primary Health Care  Primary Care  Care provided by health care professional  Care provided at the individual level  Primary Health Care (PHC)  Broad range of services  Emphasis is on prevention  Care provided at the community level

21 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. PHC Workforce  Multidisciplinary team of health care providers.  Team members include:  Primary care generalists and public health physicians  Nurses  Dentists  Pharmacists  Optometrists  Nutritionists  Community outreach workers  Mental health counselors  Translators  Other allied health professionals  Community members also important to the team

22 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. PHC Initiative  Declaration of Alma Ata (1978)  Goal of attaining a level of health that permitted all citizens of the world to live socially and economically productive lives  Healthy People 2020

23 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Primary Care  First level of the private health care system  Delivered in a variety of community settings  Americans access it through insurance programs  Managed care  Managed Care Act of 1973  HMOs, PPOs, and POS  Medicare Advantage Program

24 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Primary Care Workforce  Primary care developed in the 1960s  Needed to reexamine role of general practitioner  Primary care generalists include:  Family physicians  General internists  General pediatricians  Nurse practitioners (NPs)  Clinical nurse specialists (CNSs)  Physician assistants (PAs)  Certified nurse-midwives (CNMs)  Doctorate in Nursing Practice (DNP)

25 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Public Health System  Mandated through laws that are developed at the national, state, or local level  Organized into many levels in the federal, state, and local systems  At the local level, health departments provide care that is mandated by state and federal regulations.

26 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Federal System  U.S. Department of Health and Human Services (HHS)  Office of Global Health Affairs  U.S. Public Health Service (PHS)  Health Resources and Services Administration (HRSA)  National Institutes of Health (NIH)  Agency for Health Care Research and Quality (AHRQ)  Food and Drug Administration (FDA)  Centers for Disease Control and Prevention (CDC)  Centers for Medicare and Medicaid Services (CMS)  Departnent of Homeland Security (DHS)

27 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. State Health Department  Stand ready for disaster prevention or response  Health care financing and administration  Direct assistance to local health departments  Ongoing assessment of health needs  Board of examiners of nurses

28 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Local Health Department  Direct responsibility to the citizens on its community or jurisdictions  Variety of services and programs offered depending on the state and local health codes that must be followed, the needs of the community, and available funding and other resources