2. Introduction What Institutions Make Up the Healthcare System? What Types of Inpatient Facilities Exist in the United States? What Types of Outpatient Facilities Exist in the United States?

3. Introduction What Do We Mean by Quality of Healthcare Services? How Care Health Care Be Coordinated Among the Multiple Institutions that Provide Health Services? What Types of Healthcare Delivery Systems are Being Developed and How Can They Ensure Coordination of Health care?

4. Introduction How Can Electronic Medial Records Facilitate Coordination of Care and Improve Quality? How Is Technology Being Used to Improve the Quality of Care? What Mechanisms Are Being Used to Monitor and Ensure the Quality of Health Care? Can Disclosure of Medical Errors Contribute to Quality of Care?

5. Scenarios Health Care Institutions George didn’t have health insurance and went to the emergency room whenever he needed care. They emergency department treated him but then tried to get him connected to a primary care facility. He couldn’t go to the Veteran’s Administration facilities because he wasn’t a veteran. They sent him to the local community health center which they called the “safety-net” provider. George did go to the community health center where they tried to treat his problems and get him his medicines despite not having insurance. When he got sick, however, George went back to the emergency department. Even George agreed that it wasn’t the best way to get care but wondered what was needed to make the system work better?

6. Scenarios Health Care Institutions Laura had breast cancer and it had spread. Her medical records were everywhere in the hospital, four doctor’s offices, two emergency rooms, and an outpatient imaging facility. No one seemed to know how to put the system together. Whenever her old records were essential they asked her to go get a copy of the records and bring them to her next appointment. That worked for a while but when she ended up in the emergency room her records just weren’t available. There must be a better way, Laura through to herself. Hasn’t the health care system discovered the Internet yet?

7. Scenarios Health Care Institutions Fred ended his walk one day in the emergency room. He seemed confused about how to get home. "It looks like we are dealing with Alzheimer’s,” Fred’s doctor told Fred’s wife Sonya at their next appointment. Taking care of Fred at home was not easy. Home health aides and occasional weekend relief called "respite care" eased the burdens for a while. The new assisted living facilities looked attractive, but Fred’s family just couldn’t afford it. When Fred fell and broke his hip he required hospitalization for surgery. The hospital discharge planner arranged for a skilled nursing home for rehabilitation services. After a few weeks of rehabilitation the only alternative was long term or custodial care in a nursing home. The care at the nursing home was not what the family had expected. The staff did clean him up before the announced family visits but when the family arrived for an unannounced visit they were shocked to see Fred lying half naked in the wheelchair. The end came almost two years from the day they moved him to the nursing home. Looking back the family asked, how can we do better to address the needs of Alzheimer’s patients?

8. Characteristics of Healthcare Quality: National Committee for Quality Assurance CharacteristicMeaningExamplesHow measured? Access and Service Access to needed care and good customer service Enough primary care physicians and specialists Satisfaction of patients in terms of problems obtaining care Patient satisfaction surveys, patient grievances and follow-up, interviews with staff

9. Characteristics of Healthcare Quality: National Committee for Quality Assurance CharacteristicMeaningExamplesHow measured? Qualified providers Personnel licensed and trained and patients satisfied with services System for checking credentials, sanctions Patient satisfaction with providers of care Presence of system for checking credentials Patient satisfaction surveys

10. Characteristics of Healthcare Quality: National Committee for Quality Assurance CharacteristicMeaningExamplesHow measured? Staying healthy Quality of services that help people maintain good health and avoid illness Presence of guidelines for appropriate clinical services Evidence that patients are receiving appropriate screening tests Review of independently- verified clinical records Review of responses from patients

11. Characteristics of Healthcare Quality: National Committee for Quality Assurance CharacteristicMeaningExamplesHow measured? Getting better Quality of services that help people recover from illness Presence of method for evaluating new procedures, drugs, and devices to ensure that patients have assess to the most up-to-date care Providing specific services, such as smoking cessation Review of independently- verified clinical records Interviews with staff

12. Characteristics of Healthcare Quality: National Committee for Quality Assurance CharacteristicMeaningExamplesHow measured? Living with illness Quality of services that help people manage chronic illness Programs to assist patients to manage chronic conditions like asthma Provision of specific services, such as eye examinations for diabetics Review of independently- verified clinical records Interviews with staff

13. Type of coordination of care, intended functions and challenges with implementation Type of coordination Intended function Challenges with implementation Clinician-patient relationship Continuity as a mechanism for ensuring Coordination Development of individual relationships built on knowledge and trust over extended periods of time Multiple clinicians involved in care Team rather than individual concept of primary care Frequent changes in insurance coverage require change in health professionals

14. Type of coordination of care, intended functions and challenges with implementation Type of coordination Intended function Challenges with implementation Institutional coordination Coordination of individual’s information between institutions needed to inform individual clinical and administrative decision making Different structures and governance often lead to lack of coordination between inpatient facilities and between inpatient and outpatient facilities

15. Type of coordination of care, intended functions and challenges with implementation Type of coordination Intended function Challenges with implementation Financial coordination Implies that a patient has comprehensive coverage for services provided by the full range of Institutions Maximize the efficiency of the care received and to minimize the administrative effort required to manage the payment system Lack of comprehensive insurance coverage often means that essential services cannot be delivered or cannot be delivered at the most efficient or effective institutional site

16. Type of coordination of care, intended functions and challenges with implementation Type of coordination Intended function Challenges with implementation Coordination between Health care and Public health Coordination of services between clinical care and public heath requires communication to ensure follow-up and to protect the health of others Lack of coordination of services between public health services and clinical care is often based on lack of communication

18. Introduction How Much Money does the United States Spend on Health Care? What Types of Government-Supported Health Insurance Are Available? What Types of Employment-based Insurance are Available? What Are the Extent and Consequences of Being Uninsured and Underinsured in the U.S.

19. Introduction How Can We Describe the Healthcare Systems in General and the U.S. Healthcare System? How Can We Describe the Healthcare Systems in Canada and the United Kingdom? What Conclusion Can We Reach from These Descriptions of the U.S., Canadian and U.K. Healthcare systems?

20. Introduction How Can a Healthcare System be Scored? Using the National Scorecard, How Does the U.S. Healthcare System Compare to Other Developed Countries? How Can the Costs of Health Care Be Controlled in the United States?

21. Scenarios Health Care Systems The politicians seem to agree that health care is too expensive. However, some argue for greater regulation while others argue for less regulation. You ask yourself: what are the options for controlling costs and what are the consequences?

22. Scenarios Health Care Systems You take a job right out of college and need to select from among your company’s health care options or alternatively choose not to be insured. The choice seems quite complicated and none of them seems just right for you. How can you go about choosing between health insurance options?

23. Scenarios Health Care Systems You decide to take your chances and refuse the expensive health insurance offered by your employer. What are the consequences of not having insurance?

24. Scenarios Health Care Systems Members of the Smith family live in the U.S., Canada, and the United Kingdom. They have the same inherited disease. The recommended treatment is quite similar in the three countries and can be delivered as part of primary care. How might the delivery of care and the payment for care differ between the three countries?

25. Scenarios Health Care Systems You wonder how the U.S. ranks in terms of the performance of its health care system. You’re surprised when you find out that the U.S. is not #1 or even near the top. Why is that, you ask yourself?

26. Prototype Health Insurance Options Fee-for-Service Classic Mixed ModelHMO Classic Monthly cost to employee $400 Individual $1000 Family of 4 $1000 yearly deductible per person $200 Individual $600 Family of 4 $500 yearly deductible per person $100 Individual $400 Family of 4 No yearly deductible Choice of physician No restrictions–full coverage Physicians paid "prevailing fee“ No restrictions, but 20% copayment for Non-network Physicians paid lower discounted fee for service Staff physicians Only Full coverage Physicians paid through capitation

27. Prototype Health Insurance Options Fee-for- Service Classic Mixed ModelHMO Classic Access to specialists including OB- GYN Access without referral–full coverage Access with referral–full coverage Access without referral–20% copayment Access with referral only DrugsFull coverage as ordered $20 copayment for generic or approved/ formulary drugs $20 copayment for generic or approved/ formulary drugs

28. Prototype Health Insurance Options Fee-for- Service Classic Mixed ModelHMO Classic HospitalFull coverage as authorized by physician 80% coverage if preauthorized by plan 100% coverage if preauthorized by plan Skilled nursing Full coverage if ordered by physicians 80% coverage if found necessary by plan 100% coverage if found necessary by plan

29. Prototype Health Insurance Options Fee-for- Service Classic Mixed ModelHMO Classic Hospice100% coverage based on physician authorization 80% coverage based on plan authorization 100% coverage based on plan authorization Preventive services Not covered100% coverage in network 20% copayment out of network 100% coverage in network Emergency Department and out-of-area services 100% coverageRequires prior authorization except in emergencies as defined by “reasonable person” [J1] [AU – need “on”?] ok as edited[J1] [J2] [AU – need “on”?]Ok as edited[J2]

30. Describing the U.S. Healthcare System CategoryDescription Financing Cost over 16% of GDP and rising rapidly; Complicated mix of federal, state, employer and self-pay Type(s) of insurance and reimbursement Employment-based insurance plus government insurance through Medicare and Medicaid provide most insurance; Mix of fee-for-service, capitation, and salary with incentives are the most commonly used methods

31. Describing the U.S. Healthcare System CategoryDescription Delivery of care Mix of practice types with private practice dominant; Physicians: 1/3 Primary Care; 2/3 Specialists; Primary care increasingly based upon nurse practitioners and physician assistants; Hospitalists increasingly provide inpatient care; Need for better continuity of care between institutions and between clinicians Comprehensiveness of insurance 15% uninsured plus half again as many underinsured; Drug benefits included for elderly and those with comprehensive insurance; Preventive services increasing, but not comprehensive

32. Describing the U.S. Healthcare System CategoryDescription Cost and cost containment Over 16% of GNP and rising; Emphasis on competition as means of controlling costs, plus cost sharing by patients Patient choice Considerable choice of primary care and often direct access to specialty care; Greatly increased access for those with comprehensive insurance Administrative costs High: 25–30% of total costs including administrative costs of health insurance, clinicians and institutions, but this does not include time administrative spent by patients and their families

33. Describing the United Kingdom’s Healthcare System CategoryDescription Financing Budget about 7–8% of GDP has been rising Tax-supported comprehensive and universal coverage through National Health Service Private insurance system with overlapping coverage purchased as additional coverage by ~15% of the population with perception of easier access and higher quality Type(s) of insurance and reimbursement National Health Service is single payer with capitation, plus incentives for General Practitioners, i.e. physicians responsible for panel of patients Specialists generally salaried in National Health Service and often earn substantial additional income through private insurance

34. Describing the United Kingdom’s Healthcare System CategoryDescription Delivery of care Governmental system of healthcare delivery in National Health Service including government- owned and administered hospitals Emphasis on physicians Primary care general practitioners~ 2/3 Specialist physicians~ 1/3 General practitioners generally do not admit to hospitals Comprehensiveness of insurance National Health Service comprehensive with little cost sharing plus may cover transportation costs Incentives to provide preventive services and home care

35. Describing the United Kingdom’s Healthcare System CategoryDescription Cost and cost containment Overall limit on national spending (“Global budgeting”) Negotiated rates of capitation and salary with government as single payer within National Health Service having considerable negotiating power Patient choice National Health Service provides limited choice of general practitioners Waiting lines for services in National Health Service especially specialists and high-tech procedures Referral to specialists generally needed Greater choice with private insurance Administrative costs Greater than Canada, less than U.S.

36. U.S. health system performance as compared to best-performing countries Area of performanceU.S. score (out of 100) Healthy lives72 Quality71 Access58 Efficiency53 Equity71 Overall score65

38. Introduction What are the Goals and Role of Governmental Public Health Agencies? What are the Ten Essential Public Health Services?

39. Introduction What are the Roles of Local and State Public Health Agencies? What are the Roles of Federal Public Health Agencies? What are the Roles of Global Public Health Organizations and Agencies? How Can Public Health Agencies Work Together?

40. Introduction What Other Government Agencies Are Involved in Health Issues? What Roles Do Nongovernmental Organizations Play in Public Health? How Can Public Health Agencies Partner with Health Care to Improve the Response to Health Problems? How Can Public Health Take the Lead in Mobilizing Community Partnership?

41. Scenarios Public Health Institutions and Systems A young man in your dormitory is diagnosed with tuberculosis. The health department works with the student health service to test everyone in the dorm as well as those in his classes with a TB skin test. Those who are positive for the first time are advised to take a course of a medicine called INH. You ask: is this standard operating procedure?

42. Scenarios Public Health Institutions and Systems You go to a public health meeting and learn that many of the speakers are not from public health agencies but from the Departments of Labor, Commerce, Housing, and Education. You ask: what do these Departments have to do with health?

43. Scenarios Public Health Institutions and Systems You hear that a new childhood vaccine was developed by NIH, approved by FDA, endorsed for federal payment by the CDC, and recommended for use by the American Academy of Pediatrics. You ask: do all these agencies and organizations always work so well together?

44. Scenarios Public Health Institutions and Systems A major flood in Asia leads to disease and starvation. Some say it is due to global warming, others to bad luck. Coordinated efforts by global health agencies assisted by nongovernmental organizations (NGOs) and outside governmental donors help get the country back on its feet. You ask: what type of cooperation is needed to make all of this happen?

45. Scenarios Public Health Institutions and Systems A local community health center identifies childhood obesity as a problem in their community. They collect data demonstrating that the problem begins as early as elementary school. They develop a plan that includes clinical interventions at the health center but also includes the elementary school. They ask the health department to help them organize an educational campaign and help evaluate the results. Working together, they are able to reduce the obesity rate among elementary school children by half. This seems like a new way to practice public health, you conclude. What type of approach is this?

46. Ten Essential Public Health Services Essential service Meaning of essential service Example ASSESSMENT—Core function 1. Monitor health status to identify and solve community health problems This service includes accurate diagnosis of the community’s health status; identification of threats to health and assessment of health service needs; timely collection, analysis, and publication of information on access, utilization, costs, and outcomes of personal health services; attention to the vital statistics and health status of specific groups that are at a higher risk than the total population; and collaboration to manage integrated information systems with private providers and health benefit plans. Vital Statistics Health Surveys Surveillance, including reportable diseases

47. Ten Essential Public Health Services Essential service Meaning of essential service Example ASSESSMENT—Core function 2. Diagnose and investigate health problems and health hazards in the community This service includes epidemiologic identification of emerging health threats; public health laboratory capability using modern technology to conduct rapid screening and high-volume testing; active infectious disease epidemiology programs; and technical capacity for epidemiologic investigation of disease outbreaks and patterns of chronic disease and injury. Epidemic Investigations CDC–Epidemiology Intelligence Service State Public Health Laboratories

48. Ten Essential Public Health Services Essential service Meaning of essential service Example POLICY DEVELOPMENT—Core function 3. Inform, educate, and empower people about health issues This service includes social marketing and media communications; providing accessible health information resources at community levels; active collaboration with personal health care providers to reinforce health promotion messages and programs; and joint health education programs with schools, churches, and worksites. Health education campaigns, such as comprehensive state tobacco programs

49. Ten Essential Public Health Services Essential serviceMeaning of essential service Example POLICY DEVELOPMENT—Core function 4. Mobilize community partnerships and action to identify and solve health problems This service includes convening and facilitating community groups and associations, including those not typically considered to be health-related, in undertaking defined preventive, screening, rehabilitation, and support programs; and skilled coalition- building to draw upon the full range of potential human and material resources in the case of community health. Lead control programs: testing and follow-up of children, reduction of lead exposure, educational follow- up, and addressing underlying causes

50. Ten Essential Public Health Services Essential service Meaning of essential service Example POLICY DEVELOPMENT—Core function 5. Develop policies and plans that support individual and community health efforts This service requires leadership development at all levels of public health; systematic community- and state-level planning for health improvement in all jurisdictions; tracking of measurable health objectives as a part of continuous quality improvement strategies; joint evaluation with the medical health care system to define consistent policy regarding prevention and treatment services; and development of codes, regulations, and legislation to guide public health practice. Newborn screening program for PKU and other genetic and congenital diseases

51. Ten Essential Public Health Services Essential serviceMeaning of essential service Example ASSURANCE—Core function 6. Enforce laws and regulations that protect health and ensure safety This service involves full enforcement of sanitary codes, especially in the food industry; full protection of drinking water supplies; enforcement of clean air standards; timely follow-up of hazards, preventable injuries, and exposure-related diseases identified in occupational and community settings; monitoring quality of medical services (e.g. laboratory, nursing home, and home health care); and timely review of new drug, biological, and medical device applications. Local: Fluoridation and chlorination of water State: Regulation of nursing homes Federal: FDA drug approval and food safety

52. Ten Essential Public Health Services Essential service Meaning of essential service Example ASSURANCE—Core function 7. Link people to needed personal health services and ensure the provision of health care when otherwise unavailable This service (often referred to as “outreach” or “enabling” service) includes ensuring effective entry for socially disadvantaged people into a coordinated system of clinical care; culturally- and linguistically-appropriate materials and staff to ensure linkage to services for special population groups; ongoing “care management”; and transportation. Community Health Centers

53. Ten Essential Public Health Services Essential service Meaning of essential service Example ASSURANCE—Core function 8. Ensure the provision of a competent public and personal health care workforce This service includes education and training for personnel to meet the needs for public and personal health services; efficient processes for licensure of professionals and certification of facilities with regular verification and inspection follow-up; adoption of continuous quality improvement and lifelong learning within all licensure and certification programs; active partnerships with professional training programs to ensure community-relevant learning experiences for all students; and continuing education in management and leadership development programs for those charged with administrative/executive roles. Licensure of physicians, nurses, and other health professionals

54. Ten Essential Public Health Services Essential service Meaning of essential service Example ASSURANCE—Core function 9. Evaluate effectiveness, accessibility, and quality of personal and population- based health services This service calls for ongoing evaluation of health programs, based on analysis of health status and service utilization data, to assess program effectiveness and to provide information necessary for allocating resources and reshaping programs. Development of evidence-based recommendations [J1] [AU –OK? Sounds awk] ok as edited?[J1] [J2] [AU – case?] yes[J2]

55. Ten Essential Public Health Services Essential service Meaning of essential service Example ALL THREE IOM—Core function 10. Research for new insights and innovative solutions to health problems This service includes continuous linkage with appropriate institutions of higher learning and research and an internal capacity to mount timely epidemiologic and economic analyses and conduct needed health services research. NIH, CDC, AHRQ other federal agencies [J1] [AU –OK? Sounds awk] ok as edited?[J1] [J2] [AU – case?] yes[J2]

56. Key Federal health agencies of the Department of Health and Human Services AgencyRoles/AuthorityExamples of Structures/Activities Centers for Disease Control and Prevention (CDC) And Agency for Toxic Substances and Disease Registry (ATSDR) The lead agency for prevention, health data, epidemic investigation, and public health measures aimed at disease control and prevention The CDC administers ATSDR, which works with the Environmental Protection Agency to provide guidance on health hazards of toxic exposures. The CDC and ATSDR work extensively with state and local health departments. The CDC’s Epidemiology Intelligence Service (EIS) functions domestically and internationally at the request of governments.

57. Key Federal Health Agencies of the Department of Health and Human Services AgencyRoles/AuthorityExamples of Structures/Activities National Institutes of Health (NIH) Lead research agency. Also funds training programs and communication of health information to professional community and the public. 17 institutes in all—the largest being the National Cancer Institute. The National Library of Medicine is part of NIH Centers. The Centers include the John E. Fogarty International Center for Advanced Study in the Health Sciences. NIH is the world’s largest biomedical research enterprise with intramural research at NIH and extramural research grants throughout the world.

58. Key Federal health agencies of the Department of Health and Human Services AgencyRoles/AuthorityExamples of Structures/Activities Food and Drug Administrati on (FDA) Consumer protection agency with authority for safety of foods and safety and efficacy of drugs, vaccines and other medical and public health interventions Divisions responsible for food safety, medical devices, drug efficacy and safety pre- and post- approval

59. Key Federal health agencies of the Department of Health and Human Services AgencyRoles/AuthorityExamples of Structures/Activities Health Resources and Services Administra tion (HRSA) Seeks to ensure equitable access to comprehensive quality health care Funds community health centers, HIV/AIDS services, scholarships for health professional students

60. Key Federal health agencies of the Department of Health and Human Services AgencyRoles/AuthorityExamples of Structures/Activities Agency for Healthcare Research and Quality (AHRQ) Research agenda to improve the outcomes and quality of health care, including patient safety and access to services Supports U.S. Preventive Services Task Force, Evidence- based medicine research, and Guidelines Clearinghouse

61. Key Federal health agencies of the Department of Health and Human Services AgencyRoles/AuthorityExamples of Structures/Activities Substance Abuse and Mental Health Services Administrati on (SAMHSA) Works to improve quality and availability of prevention, treatment, and rehabilitation for substance abuse and mental illness Research, data collection and funding of local services [J1] [AU – Edits OK?] ok as re-edited[J1]

62. Key Federal health agencies of the Department of Health and Human Services AgencyRoles/AuthorityExamples of Structures/Activities Indian Health Service (IHS) Provides direct health care and public health services to federally- recognized tribes Services provided to 550 federally- recognized tribes in 35 states; Only comprehensive federal responsibility for health care, plus public health services [J1] [AU – Edits OK?] ok as re-edited[J1]

63. Global Public Health Organizations Type of agency Structure/ Governance Role(s)Limitations World Health Organization United Nations Organization Seven “regional” Semi-independent components, e.g., Pan American Health Organization covers North and South America Policy development, e.g., tobacco treaty, epidemic control policies Coordination of services, e.g., SARS control, vaccine development Data collection and standardization, e.g., measures of health care quality, measures of health status Limited ability to enforce Global Recommendation, Limited funding And complex International administration

64. Global Public Health Organizations Type of agency Structure/ Governance Role(s)Limitations International Organizations with focused agenda UNICEF UNAIDS Focus on childhood Vaccinations Focus on AIDS Limited agendas and limited financing

65. Global Public Health Organizations Type of agencyStructure/Gov ernance Role(s)Limitations International financing organizations The World Bank Other multilateral regional banks, e.g., InterAmerican and Asian Development Banks World Bank is largest international Funder; Increasingly supports “human capital” projects and reform of health care delivery systems and population and nutrition efforts; Provides funding and technical assistance primarily as loans Criticized for Standardized approach with few local modifications

66. Global Public Health Organizations Type of agencyStructure/ Governance Role(s)Limitations Bilateral governmental aid organizations USAID; Many other developed countries have their own organizations and contribute a higher percentage of their gross domestic product to those agencies than does the United States Often focused on specific countries and specific types of programs, such as the United States’ focus on HIV/AIDS, and maternal and child health May be tied to domestic politics and global economic, political, or military agendas [J1] [AU –Edit OK?] ok as re- edited [J1]

67. The 6 Sequential Steps of Community- Oriented Primary Care (COPC) Steps in the COPC process Questions to ask 1. Community definition How is the community defined based upon geography, institutional affiliation, or other common characteristics, e.g., use of an Internet site? 2. Community characterization What are the demographic and health characteristics of the community and what are its health issues? 3. Prioritization What are the most important health issues facing the community and how should they be prioritized based upon objective data and perceived need?

68. The 6 Sequential Steps of Community- Oriented Primary Care (COPC) Steps in the COPC process Questions to ask 4. Detailed assessment of the selected health problem What are the most effective and efficient interventions for addressing the selected health problem based upon an evidence-based assessment? 5. InterventionWhat strategies will be used to implement the intervention? 6. EvaluationHow can the success of the intervention be evaluated?

69. Essential Public Health and IOM Core Functions Reprinted from Public Health in America. Essential Public Health Services. Available at: http://www.health.gov/phfunctions/public.htm Accessed April 4, 2009.http://www.health.gov/phfunctions/public.htm

70. Reprinted from Public Health in America. Essential Public Health Services. Available at: http://www.health.gov/phfunctions/public.htm Accessed April 4, 2009.http://www.health.gov/phfunctions/public.htm

71. Framework for Viewing Governmental Public Health Agencies and their Complicated Connections