The Health Care Delivery System Chapter 2 The Health Care Delivery System Nursing is constantly evolving and changing. This change is driven by the U.S. health care system, which is very complex and is changing.

Challenges to Health Care Reducing health care costs while maintaining high-quality care for patients Improving access and coverage for more people Encouraging healthy behaviors Earlier hospital discharges result in more patients needing nursing homes or home care. To meet these changing conditions, organizations must run as businesses. Technology, new medications, and shortened lengths of stay increase the cost of doing business. The health care system is faced with rising costs, increased access to services, growing populations, improved quality outcomes, and threats of bioterrorism. Nurses face major challenges to prevent gaps in health care across health care settings, so individuals remain healthy and well within their own homes and communities.

Emphasis on Population Wellness Health Services Pyramid Managing health instead of illness Emphasis on wellness Injury prevention programs {Fig 2-1 here} The Core Functions Project developed the Health Services Pyramid. The shift from managing illness to managing health includes an emphasis on wellness, and the environment has enhanced quality of life. The emphasis has led to improvements in water, sewage, immunizations, and living conditions. Patient teaching has promoted better diet habits, decreased tobacco use, and improved blood pressure control. Injury prevention programs advocating seatbelt use, child seats, restraints, and helmet laws have enhanced quality of life and decreased mortality rates. [See Box 2-1 (on text p. 17) for common health care definitions that should help students begin to integrate terminology.] [Figure is on text p. 17.]

National Priorities Partnership Patient and family engagement Population health Safety/eliminating errors as possible Care coordination Palliative care for advanced illnesses Overuse/reducing waste How is health care changing? One example can be seen in the National Priorities Partnership, a group of 28 organizations from a variety of health care disciplines that have joined together to work toward transforming health care. They bring an increased focus on wellness and prevention, working through a six-part approach.

Institute of Medicine (IOM) Nurses need to be transformed by: Practicing to the full extent of their education and training Achieving higher levels of education and training through an improved education system that provides seamless progression Becoming full partners, with physicians and other providers, in redesigning the health care system Improving data collection and the information infrastructure for effective workforce planning and policy making Nursing is a caring profession with a set of ethics, values, and standards. Nurses will change with the times; however, nurses will always keep patient needs first as they are challenged with new roles and responsibilities. [What are some ways you can see yourself implementing the IOM recommendations?]

Health Care Regulation and Competition Regulatory and competitive approaches Professional standards review organizations (PSROs) Created to review the quality, quantity, and cost of hospital care provided through Medicare and Medicaid Utilization review committees (URs) Review admissions, diagnostic testing, and treatments provided by physicians who cared for patients receiving Medicare As health care costs have risen out of control, regulatory and competitive approaches have had to control health care spending. PSROs (created by the federal government) and URs are two outgrowths of the attempt to control cost. Many hospitals have added nursing case managers to meet the guidelines established by Medicare, Medicaid, and other payers.

Health Care Regulation and Competition (cont’d) Prospective payment system (PPS) Diagnosis-related groups (DRGs) Capitation Resource utilization groups (RUGs) Profitability Managed care The prospective payment system was established in 1983 to eliminate cost-based reimbursement. Each DRG has a fixed reimbursement amount with adjustments. Health care facilities (hospitals) began to receive a specific dollar amount instead of basing their fees on cost. Capitation is the payment mechanism by which providers receive a fixed amount per patient or enrollee of a health care plan. Resource utilization groups are utilized in long-term care settings. In all settings, health care providers try to manage costs so the organizations remain profitable. Managed care describes the health care system that provides administrative control over primary care services for a defined patient population.

Health Care Regulation and Competition (cont’d) Patient Protection and Affordable Care Act Access to health care for all Reducing costs Improving quality Provisions include Insurance industry reforms Increased funding for community health centers Increased primary care services Improved coverage for children The Patient Protection and Affordable Care Act, passed in 2010, focuses on major goals. As a professional registered nurse, it will be important for you to understand the basics of health care, so you can assist your patients and be an advocate for them. Table 2-1 presents examples of health care plans.

Health Care Settings and Services 1. Preventive 2. Primary 3. Secondary 4. Tertiary 5. Restorative 6. Continuing [Lead a discussion on what level or type of care is offered in each of these health care settings.] Larger health care systems have integrated delivery networks (IDNs) that include a set of providers and services organized to deliver a continuum of care to a population of patients at a capitated cost in a particular setting. Nurses are especially important as patient advocates in maintaining continuity of care throughout the levels of care.

Health Care Accreditation/ Certification Reasons: To demonstrate quality and safety To evaluate performance, identify problems, and develop solutions Accreditation earned by the entire organization Specific programs or services within an organization earn certifications. The Joint Commission and others The Joint Commission (formerly The Joint Commission on Accreditation of Healthcare Organizations) accredits health care organizations across the continuum of care, including hospitals and ambulatory care, long-term care, home care, and behavioral health agencies. Other accrediting agencies have a specific focus, such as the Commission on Accreditation of Rehabilitation Facilities (CARF) and the Community Health Accrediting Program (CHAP).

Preventive and Primary Health Care Preventive Care Primary care Focuses on improved health outcomes for an entire population Requires collaboration among health professionals, health care leaders, and community members Health promotion lowers overall costs: Reduces incidence of disease Minimizes complications Reduces the need for more expensive resources Occurs in home, work, and community settings Preventive care focuses on reducing and controlling risk factors for disease through activities such as occupational health programs. [Ask the class for some examples of primary care. Discuss health education, proper nutrition, maternal/child health care, family planning, immunizations, and control of diseases.] Table 2-2 presents examples of preventive and primary care services.

Secondary and Tertiary Care Also called acute care Focus: Diagnosis and treatment of disease Disease management is the most common and expensive service of the health care delivery system. 20% require 80% of health care spending. Fastest growing age group of uninsured? Postponement of care by uninsured Disease management is the most common and expensive service of a health care delivery system. The acutely and chronically ill represent 20% of all people in the United States and consume 80% of health care spending. What age group is the fastest growing of the uninsured? [Ask students if they know.] Young adults: 19 to 29 years old. Why? College years, leaving home, first time in the job market, and may be without health insurance. People who do not have health care insurance often wait longer before presenting for treatment; thus they are usually sicker and need more complex health care. As a result, secondary care and tertiary care (also called acute care) are more costly.

Secondary and Tertiary Care (cont’d) Settings Resource efficiency, word redesign Discharge planning—nurses’ role Hospitals Intensive Care Units Rural Hospitals Psychiatric Care Hospital emergency departments, urgent care centers, critical care units, and inpatient medical-surgical units provide secondary and tertiary levels of care. Because of work redesign, more services are available on nursing units, thus minimizing the need to transfer and transport patients across multiple diagnostic and treatment settings. Discharge planning is a centralized, coordinated, multidisciplinary process that ensures that the patient has a plan for continuing care after leaving a health care agency. [What are some ways that nurses help with discharge planning? Discuss.] An ICU is the most expensive health care delivery site because each nurse usually cares for only one or two patients at a time, and because patients in the ICU require complex treatments and procedures. Patients who suffer emotional and behavioral problems such as depression, violent behavior, and eating disorders often require special counseling and treatment in psychiatric facilities. The Balanced Budget Act of 1997 changed the designation for rural hospitals to critical access hospital (CAHs) if certain criteria were met. The CAH provides inpatient care to acutely ill or injured people before transferring them to better-equipped facilities.

Restorative Care Serves patients recovering from an acute or chronic illness/disability Helps individuals regain maximal function and enhance quality of life Promotes patient independence and self-care abilities Requires multidisciplinary approach Settings: Discharge planning and case management are equally important with restorative care as with acute care. The intensity of care has increased in restorative care settings because patients leave hospitals earlier. Patients and families are more likely to follow treatment plans and achieve optimal functioning when they are involved in restorative care. Home Care Rehabilitation Extended Care

Restorative Care: Home Care Provision of medically related professional and paraprofessional services and equipment to patients and families in their homes for health maintenance, education, illness prevention, diagnosis and treatment of disease, palliation, and rehabilitation Involves coordination of services Focuses on patient and family independence Usually reimbursed by government (such as Medicare and Medicaid in the United States), private insurance, and private pay sources [Ask students to name services commonly provided by home health nurses. Wound care, respiratory care, vital signs monitoring, elimination needs (ostomy, skin care, irrigation, insertion of catheters, peritoneal dialysis), nutrition, rehabilitation, medication administration and education, IV therapy, and laboratory studies] Nursing is one service most patients use in home care. However, home care also includes medical and social services; physical, occupational, speech, and respiratory therapy; and nutritional therapy. Most important, nurses need to be aware of other areas that directly affect home health care. [Ask students: What other knowledge is needed when you walk into a patient’s home to render care? Mention cultural practices, family dynamics, communication principles, and spiritual values.]

Restorative Care: Rehabilitation Focus: To restore patients to their fullest physical, mental, social, vocational, and economic potential Includes physical, occupational, and speech therapy, as well as social services Occurs in many health care settings, both inpatient and outpatient [Ask students in which settings rehabilitation occurs? Hospitals, rehabilitation centers, outpatient settings, home] [What types of patients require rehabilitation? Stroke, spinal cord injury, sports injuries, cardiac events] Most important, patients and families need to learn to adapt to injury and illness

Restorative Care: Extended Care Extended care facility Provides intermediate medical, nursing, or custodial care for patients recovering from acute illness or disabilities Skilled nursing facility (intermediate care) Provides care for patients until they can return to their community or residential care location Discuss how extended care facilities differ from skilled nursing facilities. Extended care used to be available primarily for older adults, but because hospitals discharge their patients sooner, the need for intermediate care settings for patients of all ages has increased.

Continuing Care For people who are disabled, functionally dependent, or suffering a terminal disease Available within institutional settings or in the home: Nursing Centers or Facilities Assisted Living Respite Care Adult Day Care Centers Hospice The need for continuing care is increasing because people are living longer. Many of these people do not have family or others to care for them.

Continuing Care: Nursing Centers or Facilities Provide 24-hour intermediate and custodial care Nursing, rehabilitation, diet, social, recreational, and religious services Residents of any age with chronic or debilitating illness Regulated by standards: Omnibus Budget Reconciliation Act of 1987 Interdisciplinary functional assessment is the focus of clinical practice: MDS, RAIs Residence can be temporary or permanent. According to the U.S. Census Bureau, 5% of those over 65 years of age live in nursing centers or other facilities. Nursing facilities succeed when they recognize residents as active participants and decision makers in their care and life in institutional settings. Staff must complete the Resident Assessment Instrument (RAI) on all residents. The RAI consists of the Minimum Dataset (MDS), Resident Assessment Protocols, and utilization guidelines of each state. Box 2-2 (on text p. 21) lists major regulatory requirements defined by OBRA 1987. [Discuss.] Box 2-3 (on text p. 21) describes the minimum data set and resident assessment protocols. [Discuss.]

Continuing Care: Assisted Living —Offers a long-term care setting with a home environment and greater resident autonomy —Provides services such as laundry, assistance with meals, personal care, housekeeping, and 24-hour oversight —Allows residents to live in their own units As one of the fastest growing industries within the United States, assisted living offers privacy, independence, and security. Some facilities provide assistance with medication administration, although nursing care services are not available directly. However, this industry has little regulation, no fee cap. It may not be the most financially sound plan for some individuals. [Photo is on text p. 22.]

Respite Care The service provides short-term relief or “time off” for persons providing home care to an ill, disabled, or frail older adult. Settings include home, day care, or health care institution with overnight care. Trained volunteers allow family caregivers to leave the home for errands or social time. The family caregiver usually not only has the responsibility for providing care to a loved one but often has to maintain a full-time job, raise a family, and manage the routines of daily living as well.

Adult Day Care Centers Provide a variety of health and social services to specific patient populations who live alone or with family in the community May be associated with a hospital or nursing home or may operate independently Offer services to patients such as daily physical rehabilitation and counseling Adult day care centers allow patients to retain more independence by living at home, which reduces costs of health care. Nurses working in day care centers provide continuity between care delivered in the home and that provided by the center.

Hospice Family-centered care that allows patients to live and remain at home Focuses on palliative (not curative) care: comfort, independence, and dignity Provides patient and family support during terminal illness and time of death Many hospice programs provide respite care, which is important in maintaining the health of the primary caregiver and family. Hospice care can be provided at home, within a homelike setting, or within the hospital setting.

Issues in Health Care Delivery Nursing shortage Competency Evidence-based practice Quality and safety in health care/ Patient-centered care Health care organizations are being evaluated on the basis of outcomes such as prevention of complications, patients’ functional outcomes, and patient satisfaction. In spite of the large number of practicing nurses, a critical shortage of nurses is projected in the United States. Box 2-4 (on text p. 23) presents the IOM’s competencies for the twenty-first century. The health care practitioner competencies are an excellent tool for measuring how well a nurse practices nursing and can serve as a guide for the development of a professional nursing career. Evidence-based practice involves the conscientious use of current best evidence, along with clinical expertise and patient preferences and values in making decisions about patient care. [See Box 2-6 on text p. 24: Nursing Work Environment and Patient Safety.] Health care providers define the quality of their services by measuring health care outcomes. Ten rules of performance in a redesigned health care system are shown in Box 2-5 (on text p. 23). Pay for performance programs and public reporting of hospital quality data are designed to promote quality, effective, safe patient care. Box 2-7 (on text p. 25) reviews Dimensions of Patient-Centered Care. [Discuss.] By learning early what a patient expects with regard to information, comfort, and availability of family and friends, nurses are able to better plan patient care.

Issues in Health Care Delivery (cont’d) Magnet Recognition Program Nursing-sensitive outcomes Nursing informatics and technological advancements Globalization of health care The American Nurses Credentialing Center (ANCC) established the Magnet Recognition Program to recognize health care organizations that achieve excellence in nursing practice. [See Boxes 2-8, Magnet Model and Forces of Magnetism, and 2-9, Nursing Quality Indicators (both on text p. 26).] Nursing informatics uses information and technology to communicate, manage knowledge, mitigate error, and support decision making. Nurses gain or use information when they organize, structure, or interpret data. Knowledge develops when nurses combine and identify relationships between different pieces of information. Technological advancements influence where and how nurses provide care to patients and can help nurses improve direct care processes, patient outcomes, and work environments. [Ask students what they think of recent technological advancements—do they help or hinder the nurse’s effectiveness?] Globalization, the increasing connectedness of the world’s economy, culture, and technology, is one of the forces reshaping the health care delivery system. Children, women, and older adults are vulnerable populations most threatened by urbanization.

The Future of Health Care Change opens up opportunities for improvement. Health care delivery systems need to address the needs of the uninsured and the underserved. Health care organizations are striving to become better prepared to deal with these and other challenges in health care. The solutions necessary to improve the quality of health care depend largely on the active participation of nurses. [Discuss: Is health care in the United States better or worse than that in other industrialized nations?] Nurses need to remain knowledgeable and proactive about issues in the health care delivery system to provide quality patient care and positively affect health.