1. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Chapter 4 Health Care Delivery, Quality, and the Continuum of Care

2. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Health Care Delivery: Organizational Frameworks Public sector –Official or governmental agencies U.S. Department of Health and Human Services –Voluntary agencies ANA, American Medical Association (AMA), American Cancer Society (ACS), and American Heart Association (AHA) –Nonprofit agencies (continued)

3. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Health Care Delivery: Organizational Frameworks Private sector –All nongovernmental sources –Health insurance industry –Pharmaceutical companies –Suppliers of health care technology and equipment

4. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Health Care Team Nurse (RN) Physician (MD, DO) Physician assistant (PA) Pharmacist (RPh) Dentist (DDS, DMD) Dietitian (RD) (continued)

5. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Health Care Team Social worker (SW) Respiratory therapist (RT) Physical therapist (PT) Occupational therapist (OT) Chaplain Unlicensed assistive personnel (UAP)

6. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Nurse: Roles and Functions Caregiver Teacher Advocate Manager Expert Case manager Team member

7. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Advanced Practice Nurse: Roles and Functions Diagnose primary health problems Prescribe therapies Promote continuity of care Specialize in variety of areas

8. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Reimbursement Methods Private insurance Managed care –HMO –Preferred provider organization (PPO) (continued)

9. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Reimbursement Methods Government plans –Medicare –Medicaid –State Children’s Health Insurance Program (SCHIP)

10. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Factors Influencing the Delivery of Health Care Cost Access Quality Nursing supply and demand

11. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Cost Contributing factors to high costs: –Aging population –Technological advances –Surplus of hospital beds –More people living with chronic illnesses Barrier to access

12. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Access Limiting factors: –No insurance –Cultural barriers –Few providers in rural and inner-city areas –Limited access to ancillary services

13. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Quality Threats: –Inappropriate use of resources –Inappropriate substitution of personnel for registered nurses –Imbalance in supply and demand of registered nurses

14. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Nursing Supply and Demand Nursing shortage could reach 500,000 by 2025 Declining number of nursing faculty

15. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Responses to Health Care Changes Nursing’s agenda for health care reform Public versus private programs Vulnerable populations Community nursing organizations

16. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Continuum of Care Levels of care Health care settings Fragmentation of care

17. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Levels of Care Primary –Health promotion and illness prevention Secondary –Diagnosis and treatment Tertiary –Rehabilitation

18. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Health Care Settings Hospitals Extended care facilities Home health agencies Hospices Outpatient settings (continued)

19. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Health Care Settings Schools Industrial clinics Managed care organizations Community nursing centers Rural primary care hospitals

20. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Fragmentation of Care Result of multiple providers and various care settings Loss of individuality for client Seamless service –Attempt to overcome delivery of fragmented services

21. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Quality Management in Health Care Quality –Meeting or exceeding client requirements Right thing Right way First time (continued)

22. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Quality Management in Health Care Quality assurance Continuous quality improvement Total quality management

23. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Factors Influencing Quality Consumer demands Financial viability Professional accountability Regulatory requirements Progress in quality improvement techniques Changes in health care delivery (continued)

24. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Factors Influencing Quality Legal implications of quality improvement –Nurses must understand roles that law, regulations, and ethics play in quality movement Federal regulations –Agencies regulate health care standards Imperative to adhere to standards

25. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Quality and Health Care Economics Rising costs Poor quality care Doing more with less Increasing efficiency and improving quality

26. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Principles of Quality Improvement Quality as central theme Organizational culture supports quality Personal responsibility Continual education Monitored performance Use of scientific approach Accurate information

27. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Customer Satisfaction Customers –Clients –Suppliers –Third-party payers –Families –Visitors –Employees –Community (continued)

28. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Customer Satisfaction Satisfaction requires putting customer first

29. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Organizational Structure for Quality Management Organizational culture –Leadership –Teamwork

30. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Process Improvement Tools for measuring quality: –Audits –Peer reviews –Benchmarking –Clinical pathways

31. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Nursing’s Role in Quality Management Roles: –Clinician –Team member –Manager Must continue to strive for excellence

32. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Trends in Health Care Delivery Aging U.S. population Diversity Single-parent families Growth in outpatient settings Technology Disease prevention More responsibility for care