Nursing and the Health Care System Chapter 1 Nursing and the Health Care System

Learning Objectives Identify 10sites of employment for licensed practical/vocational nurse (LPN/LVN) in medical surgical nursing. Describe each of the roles of the LPN/LVN. Explain how a health maintenance organization (HMO)and a preferred provider organization (PPO) differ. Differentiate between Medicare and Medicaid in areas of eligibility and services provided. Describe how hospitals are reimbursed under the diagnosis-related group (DRG) system of Medicare. Discuss four factors that contribute to rising health care costs.

Learning Objectives Define and explain the importance of holistic care. Discuss how psychological, social, cultural, and spiritual needs are incorporated. List four practice settings in which LPNs may find employment. Identify segments within various levels of health care. Discuss how the standards of practice for the LPN/LVN are applied in the clinical setting. List practice areas in the community in which you could be employed as a vocational nurse.

Common Goals of the LPN/LVN Uphold clinical standards Provide safe patient care Teach patients Communicate effectively Work as a collaborative member of the health care team Advocate for the patient To accomplish these goals, the practical nurse takes on the role of caregiver, educator, collaborator, and manager. The nurse's goal is to encourage growth toward wellness so that the patient can once again be self-reliant. What are interventions?

Roles of the Practical Nurse Caregiver Implement interventions to improve, maintain, or restore health Educator Heath teaching and counseling to promote wellness, prevent illness Collaborator Work with RN and health care team to provide continuity of care Manager Assign minor tasks to nurse assistant or other ancillary personnel

Current Nursing Practice Nurse Practice Acts Established in each U.S. state and Canadian province Defines the role and scope of practice of LPN/LVNs Regulate the practice of nursing Designed to protect the public and define legal scope of practice The practice acts generally define activities in which nurses may engage, state the legal requirements and titles for nursing licensure, and establish the education needed for licensure. What are the Standards of Nursing Practice?

Practice Settings Hospitals Extended care facilities Outpatient surgery Intermediate care units (step down units) IV therapy teams Emergency rooms Extended care facilities Intermediate or long-term care for rehabilitation or custodial care Physicians’ offices Ambulatory patients receive preventive care or treatment of illness or injury

Practice Settings Ambulatory clinics Ambulatory patients come for preventive care or treatment of an illness or injury Rehabilitation Services Group Homes Assisted living facilities Hospices Supportive treatment for patients who are terminally ill Home health care Military Prisons

Practice Settings: Expanded Role of the LPN/LVN The most common site of employment for the LPN/LVN is the nursing home or long-term care unit. Charge nurse/manager of care Delegation and assignment

Delegation and Assigning Delegating: Transferring to competent unlicensed assistive personnel (UAP’s) the authority to perform a selected nursing task/activity in a selected patient situation within the job description of the LPN/LVN. Voluntary function Not all states allow LPN/LVN’s to delegate Assignment: Describes the distribution of work that each staff member is to accomplish on a given shift or work period.

Delegation: 5 Rights of Delegation Right task Right circumstances Right Person Right Direction/Communication Right Supervision

Delegation What should the nurse consider before delegating a specific task?

Delegation: Answer Know the scope of practice Be aware of the staff competency and experience. Provide adequate explanation and oversight of the task..

Health Care Financing: Definitions of Terms Fee for service Provider Deductible Copayment Co-insurance Capitataion Appeared in the late 1960s and 1970s. Because research is showing better patient outcomes with more of the care being delivered by nurses, there is a trend back to total patient care. How is the productivity level increased with primary nursing?

Health Care Financing: Definition of Terms Group Health Insurance Managed Care-Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs) Government sponsored health insurance- Medicare and Medicaid Retrospective payment system Diagnosis Related Groups (DRG) Prospective Payment System (PPS)

Goals For Health Care Cost containment- the US spend more money on health care than any other industrialized nation, yet have pooper heath outcomes than other countries (infant mortality, life expectancy) Health promotion and Healthy People 2020 Holistic care

References deWit, S. (2013). Medical-surgical nursing: Concepts & practice. 2nd ed. St Louis: Saunders Elsevier.

Question? What actions can you take as a nurse to help with cost containment?

Today’s Health Care System: Preferred Provider Organizations (PPOs) Offer discount on fees in return for large pool of potential patients Allows insurance companies to keep premium rates lower and makes insurance coverage of employees less expensive for employers There are usually a larger number of physicians to choose from in a PPO than in an HMO. Who may contract with PPOs?

Today’s Health Care System: Health Maintenance Organizations (HMOs) Enroll patients for a set fee per month Provide limited network of physicians, hospitals, and other providers from which to choose One goal is to keep patients healthy and out of the hospital What are the names of two national HMOs? Patients must be referred by their primary physician for diagnostic tests, hospitalization (including emergency room visits), and consultation with a specialist.

Today’s Health Care System: The Managed Care Environment Considerable controversy about effectiveness of this approach Nurses must constantly think about cost containment while trying to give optimal care to patients Documentation is exacting because every treatment and each use of equipment must be documented with evidence showing it is needed. Why is vigilant assessment with documentation more important than ever?

Medicare and Medicaid Medicare: Federal program that partially finances health care for all persons over 65 years old age. Have at least a 10 year record in Medicare-covered employment and are citizens or permanent resident of US. Given to patients who have end-stage renal disease and permanent and total disability. Medicaid: Joint funding state and federal program provides medical assistance for families and individuals with low incomes and poor resources

Healthy People 2020 Attain high quality, longer lives free of preventable disease, disability, and the opportunities for progress. Achieve health equality, eliminate disparities, and improve the health of all groups. Create social and physical environments that promote good health for all. Promote quality of life, healthy development, and healthy behaviors across all life stages.

Holistic care Involves being aware of and attending to the following needs of the patient: Psychological Physiologic Social Cultural Spiritual

Meeting Psychological Needs Use of empathy Promote therapeutic nurse patient relationships Establish trust Use of therapeutic communication Maintain patient self-esteem Display competence Ensure pain control Use therapeutic touch

Meeting Social Needs Inability to assume personal responsibilities can be a source of worry for patients and may interfere with positive outcomes after illness or surgery Financial needs Home situations-responsibilities, family role

Meeting Cultural Needs Nurses must be open-minded, nonjudgmental Cultural differences- social class, religion, ethnicity, or sexual preference

Meeting Spiritual Needs Spirituality is an essential part of being human. The spirit is the inner most part of an individual, the spirit encompasses the beliefs and values that provide strength and hope, awareness of self, and understanding of life's meaning and purpose.

References deWit, S. (2013). Medical-surgical nursing: Concepts & practice. 2nd ed. St Louis: Saunders Elsevier.