The Health Care Delivery System Chapter 5 The Health Care Delivery System Ch 5 The Health Care Delivery System

Health Care Delivery System Method for providing services to meet health needs of individuals Levels of Health Care Services Primary care Secondary care Tertiary care Health Care Delivery System: Method for providing services to meet health needs of individuals Levels of Health Care Services Primary care Promote wellness and prevent illness or disability. Purposes are to promote wellness and to prevent illness or disability. A primary care provider (a physician or a nurse practitioner) coordinates the care of each client. The primary care provider assists the client in adopting or maintaining health-promoting behavior with an emphasis on illness prevention. Some examples include teaching individual clients how to select and follow a well-balanced, nutritious diet or to adopt a regular exercise program such as walking daily; having clients who smoke begin a smoking cessation program; or monitoring client immunizations to see that they are current. At the community level, primary care providers can become involved in reducing air pollution and supporting maintenance of a clean water supply. Secondary care Diagnosis and treatment after client exhibits symptoms of illness. Purpose is to provide early diagnosis and treatment of disease. Secondary care services are usually provided by hospitals or ambulatory care centers. Some examples include hospitalizing a client for treatment of a heart attack; prescribing medications to control high blood pressure or high cholesterol levels; or having a suspicious breast lesion surgically removed. Tertiary care Attempts to restore individuals to state of health that existed before illness developed. Purpose is to reduce the disability associated with some illnesses, with the aim of restoring a client’s health status to the highest level possible. Some examples include restoring function to extremities injured in an automobile or other type of accident or assisting a client to learn to walk again after amputation of a leg

U.S. Health Care Delivery System Involves many providers, consumers, settings, personnel, and services Providers and Consumers Health care services delivered by: Public sector Public/private sector Private sector U.S. Health Care Delivery System Involves many providers, consumers, settings, personnel, and services Providers and Consumers Health care services delivered by: Public sector Funded by tax monies Public/private sector Federal regulations guide care provided and reimbursement Private sector Independent agencies reimbursed on fee-for-service basis

Health Care Settings Acute care hospitals Extended-care facilities Outpatient settings Home health care agencies Schools Hospice Health care settings Acute care hospitals Extended-care facilities Outpatient settings Home health care agencies Schools Hospice

See text p 95 Health Care Economics Health Care Personnel and Services Exist within various health care settings Health Care Team Multidisciplinary Health Care Economics Private Insurance, Managed Care, HMOs, PPOs, EPOs Health Care Personnel and Services Exist within various health care settings May include: Nursing units Specialized client care units Diagnostic departments Therapy departments Support services Health Care Team-Multidisciplinary Nurses LPN, RN, advanced practice registered nurse (APRN) See text p 95 Health Care Economics Private Insurance: System of financing health care services in United States (U.S.). Individuals pay monthly premiums for coverage. Insurers pay only for services they deem necessary Physicians, physicians assistants, and dentists Pharmacists Dieticians Social workers and chaplains Therapists Respiratory (RT) Physical (PT) Occupational (OT) Speech (ST)

Federal Government Plans Medicare Covers individuals over age 65, permanently disabled, and with end-stage renal disease Medicaid Provides services for aged poor, disabled, and low-income families with children Children’s Health Insurance Program (CHIP) Provides coverage to uninsured children There are several public insurance plans offered by the federal government, including Medicare, Medicaid, and the Children’s Health Insurance Program. Medicare is designed to cover people over age 65 and those who are permanently disabled or have end-stage renal disease. Medicaid is a program shared between federal and state governments and is designed for those deemed “medically indigent”; the federal government defines minimal services that must be provided, and each state decides who qualifies for this program. The Children’s Health Insurance Program provides health care to uninsured children whose families do not earn enough to afford private insurance but earn more than allowed for Medicaid eligibility. The major factor driving reform of the health care delivery system is containment of the costs associated with providing services. (continued)

Factors Influencing Health Care Cost Access Quality Factors that increase health care cost: Cost: Oversupply of specialized providers. Surplus of hospital beds. Passive role of consumer. Aging population. Increase in people with chronic illnesses. Health-related lawsuits Access: Limited by: Lack of insurance through employer. High cost of individual insurance. Preexisting conditions. Cultural barriers. Shortages of health care providers. Limited transportation. Working parents unable to take time off Quality: Inappropriate use of resources can be traced to several factors, including. Litigious environment and practice of “defensive medicine”. Belief that more is better. Lack of access to and continuity of services

Challenges within the Health Care System Disillusionment with providers Loss of control Changing of practice settings Decreased hospital use Vulnerable populations Ethical issues Challenges within the Health Care System: Disillusionment with providers: Consumers are concerned about the high costs of medical care and have begun to question medical practices. Issues related to provider greed and waste within the health care delivery system have been identified as major problems. Public perception of nurses, however, remains positive; clients believe that nurses enhance quality of care and contribute to reducing costs because of their focus on holistic care. Loss of control: Because health care insurance companies or managed care organizations now determine the care that clients can receive, providers often lose control over the care provided to their clients. Clients also feel loss of control because of issues related to obtaining or maintaining health care benefits. Decreased hospital use: Although hospitals remain at the heart of the health care delivery system in the United States, many factors have contributed to the current decrease in hospital clients, including the trend toward earlier discharge following surgery or complex inpatient treatment, the growth of outpatient services and facilities, technologic advances, and changes in insurance reimbursement practices. One consequence is the restructuring of hospitals, including the expansion of the range of services provided, the merging of hospitals, and the use of nonlicensed personnel. Changing practice settings: Nurses who work in hospitals are caring for clients who are more acutely ill. The growth of home health services and long-term care institutions is continuing, and there is a greater need for nurses in these settings, based in part on the growth of the number of older adults. The homeless population is also growing, requiring more nurses to work in community-based settings. Ethical issues: The conflict of containing costs versus providing compassionate care provides a major challenge to the U.S. health care delivery system. Many clients’ health care needs are greater than the available resources, resulting in such actions as establishing plans for allocation of health care resources for those who are terminally ill. Vulnerable populations: As more people are unable to gain access to health care services because of age, lack of insurance coverage, and poverty, the number of medically unserved or underserved, including children and the homeless, is increasing. The homeless population often uses inner-city hospitals for care, creating an economic burden on such facilities and a lack of follow-up care. Residents of rural areas may also lack ready access to health care providers and facilities.

Nursing’s Response Nursing’s Agenda for Health Care Reform, 1991 Public policy agenda Endorsed by 70 organizations Provided framework for health care policy changes Established legislative program to implement proposed changes Nursing’s Response: Nursing’s Agenda for Health Care Reform, a platform developed by the American Nurses Association (ANA) in 1991 to address issues of cost, access, and quality within the health care delivery system, has been endorsed by many organizations as a public policy agenda. This document was updated in 2005, and is now called ANA’s Health Care Agenda. The foundation of the platform is delivery of health care services in environments that are easily accessible and consumer friendly. Nurses will work to promote consumer self-care through education and legislative efforts. Another approach, proposed by the Agency for Health Care Policy and Research, is to establish standards of care, guidelines for the diagnosis and treatment of particular health problems. Nurses have a critical role in ensuring that the established guidelines are followed. The development of advanced practice nursing is another approach to providing quality primary health care services, particularly to those with inadequate or limited access to health care services. Advanced practice nurses are registered nurses who have advanced education and clinical training in areas such as midwifery, adult health, and family health care. Nurses strongly support the integration of public and private sector health care services; these services should be available for those who have resources and those who do not. Services that emphasize consumer health promotion and disease prevention in primary care settings can be expanded to ensure public health; many of these services are being provided by nurses and should be expanded to meet current health needs.

Standardization of Care Agency for Health Care Policy and Research (AHCPR), 1990 Standards of diagnosis and treatment for high-volume, expensive disease conditions to which health care community can be held Currently 18 guidelines Standardization of Care Agency for Health Care Policy and Research (AHCPR), 1990 Standards of diagnosis and treatment for high-volume, expensive disease conditions to which health care community can be held Currently 18 guidelines

Advanced Practice Nurses Work with clients to prevent disease and promote health Prescribe less expensive diagnostic tests Charge less for services May prescribe some medications depending on state regulations Advanced Practice Nurses Work with clients to prevent disease and promote health Prescribe less expensive diagnostic tests Charge less for services May prescribe some medications depending on state regulations

Public versus Private Programs Competition between public and private sectors has encouraged quality and progress Public dollars needed to help poor and uninsured Minimal national standards should allow full access to health care to all Public versus Private Programs: Competition between public and private sectors has encouraged quality and progress Public dollars needed to help poor and uninsured. Minimal national standards should allow full access to health care to all

Current Public Health Problems Prevalence of overweight population Emergence of drug-resistant strains of tuberculosis and other infections Presence of toxic environmental conditions Community Health Nursing has rich legacy of contributions to community health Focus on prevention and primary care Current Public Health Problems Prevalence of overweight population Emergence of drug-resistant strains of tuberculosis and other infections Presence of toxic environmental conditions Community Health Nursing has rich legacy of contributions to community health Focus on prevention and primary care

Trends and Issues Aging of population Increasing population diversity More single parents and children living in poverty Growth of outpatient care Technological advances Managed care for medically indigent Incentives for preventive care Federal funding for provider education Managed care dominating service delivery Focus on quality improvement Trends and Issues Aging of population Increasing population diversity More single parents and children living in poverty Growth of outpatient care Technological advances (continued)