Basic Nursing: Foundations of Skills & Concepts Chapter 5 THE HEALTH CARE DELIVERY SYSTEM

What is the Health Care Delivery System? A mechanism for providing services that meet the health-related needs of individuals.

Three levels of Health Care Primary Secondary Tertiary

Primary Care Goal: To decrease the risk to a client (individual or community) of disease or dysfunction. Approach: General health promotion. Protection against specific illnesses.

Secondary Care Goal: To alleviate disease and prevent further disability. Approach: Early detection and intervention.

Tertiary Care Goal: To minimize disability associated with chronic or irreversible conditions. Approach: Restorative and rehabilitative activities to attain optimal level of functioning.

The U.S. System Health care services are delivered and financed by three sectors: The public (official, voluntary, and nonprofit agencies) Public/private Private (hospitals, extended-care facilities, hospices, schools, etc.)

Health Care Settings Hospital Extended-care facilities Home health care agencies Hospices Out-patient settings Schools Industrial Clinics Managed care organizations Community nursing centers Rural primary care hospitals

Health Care Team Members Health care is delivered by a multidisciplinary team, all working together. Examples include: Physician (MD) Nurse (RN, LP/VN) Nurse Assistant (CAN) Registered Dietician (RD)

Economics of Health Care The U.S. health care system has a diverse base: 32% private insurance 14.8% medicaid 18.8% Medicare 11.8% Other public programs 17.4% Out of Pocket 4.5% Other private

Private Insurance Model Basis of U.S. system Individual pays monthly premiums for coverage and receives access on an as needed basis

Managed Care Model Developed to provide coordinated care with an emphasis on prevention A system of providing and monitoring care wherein access, cost, and quality are controlled before or during delivery of service

HMOs, PPOs and EPOs Health Maintenance Organizations (HMOs) have a single point of entry. Entry into the health plan through a point designated by the plan. Preferred Provider Organizations (PPOs) allow individuals to access health care from within a pool of providers. Exclusive Provider Organizations (EPOs) are similar to PPOs except that care is intended to be delivered exclusively from within the selected pool of providers.

Federal Insurance Plans Medicare: Provides health care coverage for elderly persons and disabled persons. Medicaid: Federal and Local administered program that provides health care services for the poor.

Factors Influencing Health Care Cost Access Quality

Cost Issues Many factors influence costs: An oversupply of specialized providers A surplus of hospital beds The passive role assumed by most consumers. The aging of the population. The increased number of people with chronic illnesses. Unnecessary use of services (e.g. additional diagnostic testing) and increase in health-related lawsuits.

Access Issues Many factors influence an individuals ability to access the health care system: Inadequate or cost of insurance Cultural barriers Limited access to ancillary services (e.g. child care, transportation) Certain preexisting conditions making it difficult to obtain insurance Shortage of providers in rural or inner city areas

Quality Issues Many factors influence the quality of care individuals receive: The litigious environment and response toward defensive practice (e.g. ordering all possible tests). The widely held American belief that more is better. Lack of access to and continuity of services result in subsequent misuse of acute services.

Challenges The U.S. Healthcare system faces some serious challenges: Public’s disillusionment with providers Public’s loss of control over health care decisions Changes in practice settings Decreased use of hospitals and related impact on quality of care Ethical issues Health care needs of vulnerable populations

Nursing’s Response to the Challenges The nursing profession has responded to the multiple challenges in health care delivery by proposing a plan for reform.

Nursing’s Vision for the Future To provide health care services that emphasize PREVENTION and PRIMARY HEALTH CARE for clients, thereby helping to reduce costs and increase the quality of health care