The Health Care Delivery System Chapter 2 NUR 215 Professor Stewart

What is a Health Care Delivery System? It is a mechanism for providing services that meet the health-related needs of individuals. Nursing is a major component of the U.S. health care delivery system. Copyright by Delmar, a division of Thomson Learning

Organizational Framework Public Sector (includes official and voluntary) Private Sector No single agency or group controls the entire health care system. Copyright by Delmar, a division of Thomson Learning

Public Sector Federal Level (DHHS) State Level (Dept. of Health) Local Level Health Units Environ-mental Health and Safety Health Records Mainten-ance (Vital Statistics) Individual Health Services Public Health Education Commun-icable Disease Control Copyright by Delmar, a division of Thomson Learning

Copyright by Delmar, a division of Thomson Learning Private Sector Largest segment of the health care system (most healthcare facilities are run by private for-profit or not-for-profit corporations) Also includes health insurance industry, pharmaceutical companies, suppliers of health care technology and equipment Copyright by Delmar, a division of Thomson Learning

Reimbursement Methods Private Insurance Managed Care Health Maintenance Organizations (HMOs) Preferred Provider Organization (PPO) Federal government insurance plans Medicare Medicaid Copyright by Delmar, a division of Thomson Learning

Copyright by Delmar, a division of Thomson Learning Managed Care Goal: The delivery of services in the most cost-efficient manner possible. Seeks to control costs by monitoring delivery of services and restricting access to expensive procedures and providers. Copyright by Delmar, a division of Thomson Learning

Copyright by Delmar, a division of Thomson Learning Managed Care (cont.) Health Maintenance Organizations (HMOs) Capitated Rates Primary care providers (“Gate-keepers”) Preferred Provider Organizations (PPO) Networks Copyright by Delmar, a division of Thomson Learning

Federal Government Plans Medicare – for older adults and people with disabilities Diagnosis-related groups (DRGs) Medicaid – For the economically disadvantaged Copyright by Delmar, a division of Thomson Learning

Copyright by Delmar, a division of Thomson Learning Health Care Today Primary Care Provider Limitations Referrals Decreased Hospitalization Care at Home Less Service Oriented and More Business Oriented Copyright by Delmar, a division of Thomson Learning

Is health care a right or a privilege?

Copyright by Delmar, a division of Thomson Learning Levels of Health Care Primary Secondary Tertiary Copyright by Delmar, a division of Thomson Learning

Copyright by Delmar, a division of Thomson Learning Primary Care Goal – To decrease the risk to client for disease or dysfunction Focus – General Health Promotion; Protection against specific illnesses Examples: Teaching, Lifestyle Promotion, Immunizations Copyright by Delmar, a division of Thomson Learning

Copyright by Delmar, a division of Thomson Learning Primary Care Settings School health services Occupational health services Physicians’ offices Clinics Nursing centers Block and parish nursing Copyright by Delmar, a division of Thomson Learning

Copyright by Delmar, a division of Thomson Learning Secondary Care Goal: Early intervention to alleviate disease and prevent further disability Focus: Early detection and intervention Examples: Screening, diagnosis, acute care, surgery Copyright by Delmar, a division of Thomson Learning

Copyright by Delmar, a division of Thomson Learning Secondary Settings Hospitals/medical centers Emergency departments Medical units Intensive care Psychiatric facilities Rural hospitals Copyright by Delmar, a division of Thomson Learning

Copyright by Delmar, a division of Thomson Learning Tertiary Care Goal: To minimize effects of and permanent disability due to chronic or irreversible condition Focus: To restore and rehabilitate to obtain optimal level of function Examples: Education and retraining; Environmental modifications Copyright by Delmar, a division of Thomson Learning

Tertiary Care Settings Home health care Rehabilitation centers Extended care facilities Copyright by Delmar, a division of Thomson Learning

Copyright by Delmar, a division of Thomson Learning Health Care Team Nurse (RN) Physician (MD, DO) Physician assistant (PA) Pharmacist (RPh) Dentist (DDS, DMD) Dietitian (RD) Social worker (SW) Respiratory therapist (RT) Physical therapist (PT) Occupational therapist (OT) Chaplain Unlicensed assistive personnel (UAP) Copyright by Delmar, a division of Thomson Learning

Copyright by Delmar, a division of Thomson Learning Roles of the Nurse Caregiver Teacher Advocate Manager Expert Case manager Team member Copyright by Delmar, a division of Thomson Learning

Nurses and the Health Care Team Nurses usually coordinate the care provided by a multidisciplinary team The nurse is always accountable for the overall nursing care of the client. Copyright by Delmar, a division of Thomson Learning

Copyright by Delmar, a division of Thomson Learning Delegation Designed to make the work of client care more efficient May delegate to an LPN or unlicensed assistive personnel (certified nurses aide, personal care assistant, nursing assistant) Copyright by Delmar, a division of Thomson Learning

Factors Influencing the Delivery of Health Care Cost Access Quality Copyright by Delmar, a division of Thomson Learning

Copyright by Delmar, a division of Thomson Learning Cost Factors contributing to the increase in cost of health care An aging population Technological advances Surplus of hospital beds Increased number of people with chronic illness Increase in health related lawsuits Copyright by Delmar, a division of Thomson Learning

Access - Limiting Factors Inability to obtain insurance (due to high cost, pre-existing conditions, or no provision for insurance) Cultural barriers Shortages of health care providers (esp. in rural areas) Limited access to services (due to lack of transportation, childcare issues) Copyright by Delmar, a division of Thomson Learning

Copyright by Delmar, a division of Thomson Learning Quality Estimated that 30%-40% of diagnostic/medical procedures performed in U.S. are unnecessary Inappropriate use of resources due to: Litigious environment that creates tendency toward defensive practice. Resource consumption (belief that more is better) Lack of access to and continuity of services with subsequent misuse of acute care services Quality frequently compromised by substitution of UAP for RNs Copyright by Delmar, a division of Thomson Learning

Case Studies

Challenges Within the Health Care System Disillusionment with professionals Loss of Control Decreased Hospital Use Changing Practice Settings Ethical Issues Copyright by Delmar, a division of Thomson Learning

Nursing’s Response to Health Care Challenges Nursing’s Agenda for Health Care Reform Advanced practice Public health Copyright by Delmar, a division of Thomson Learning