What is the Health Care Delivery System?
A mechanism for providing services that meet the health-related needs of individuals.
Primary Care
Goal: To decrease the risk to a client (individual, family, or community) of disease or dysfunction.
Approach: General health promotion. Protection against specific illnesses.
Health Promotion
Illness Prevention
Secondary Care
Goal: To alleviate disease and prevent further disability.
Approach: Early detection and intervention.
Diagnosis
Early detection
Treatment
Tertiary Care
Goal: To minimize disability associated with chronic or irreversible conditions.
Approach: Restorative and rehabilitative activities to attain optimal level of functioning.
Rehabilitation
Health restoration
Palliative care
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 Agencies
Government agencies
Public health services
Physicians' offices
Primary care
Routine health screening
Diagnosis and treatment
Ambulatory care centers
Diagnostic treatment facilities
Minor surgery
Occupational health clinics
Run by companies for employees
H
Reimbursement Methods
Diverse reimbursement base
Private funding
Public funding
Fee-for-service method
Recipient pays the provider for health care services when they are performed
Private Insurance Model
Basis of U.S. system
Individual pays monthly premiums for coverage and receives access on an as needed basis
Costs of premiums limit access for many
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
Health Maintenance Organizations
Single point of entry. Entry into the health plan through a point designated by the plan.
Emphasizes wellness.
Fee is preset and prepaid
Provide services to a group of enrolled persons
Preferred Provider Organizations
Allow individuals to access health care from within an organization of providers.
Fees are preset and prepaid
Networks of providers that give discounts to sponsoring organization
Members are not mandated to select a specific primary care provider but must
Government Plans
Third-party payer beginning in 1965
Centers for Medicare and Medicaid Services (CMS) is federal agency that regulates Medicare and Medicaid expenditures
Created diagnosis-related groups (DRGs) to curtail spending
Medicare
part A includes post-hospital extended care and home health benefits. workers with permanent disabilities and their dependents who are eligible for disability insurance under Social Security. Also added extremely expensive hospital care, catastrophic care
Medicaid
State and federal venture for the 'medically indigent
for Social security act. medicaid is a federal public assistance program paid out of general taxes to people who require financial assistance, such as people with low income. Paid by federal and state
State Children's Health Insurance Program
-established 1997. state and federal collaborative to provide insurance coverage for poor and working-class children. coverage includes visits to primary health care providers, prescription medicines, and hospitalization.
DRGs
Inclusive rate established for each episode of hospitalization based on:
Client's age
Diagnosis
Presence or absence of surgery
Co-morbidity
HACs
A serious preventable adverse event that is a hospital-acquired condition (HAC)
Examples: Falls, severe pressure ulcers, surgical site infections
Medicare Modernization Act and Deficit Reduction Act of 2005 permits the CMS to reduce or refuse reimbursemen
Factors Influencing Health Care
What is Driving Health Care Costs?
Intensity of services
Prescription drugs and technology
Aging of the population
Administrative costs
Factors Influencing Health Care
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
Factors Influencing Health Care
Quality Issues
Many factors influence the quality of care individuals receive:
he 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 c
Agency for Healthcare Research and Quality (AHRQ)
Federal agency that is home to research centers that specialize in major areas of health care research such as quality improvement and patient safety, outcomes and effectiveness of care, clinical practice and technology assessment, and health care organiz
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
Ethical issues
Health care needs of vulnerable populations
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
Primary Health Care
essential health care; based on practical, scientifically sound, and socially acceptable method and technology; universally accessible to all in the community through their full participation; at an affordable cost; and geared toward self-reliance and sel
Primary Care
integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community (IOM, 1994
Community-based Nursing (CBN)
Directed toward specific individuals
Care is not confined to one practice setting, extending beyond institutional boundaries
Involves a network of nursing services, for example
Ambulatory centers
Home health
School health
Hospice
Community-based Health Care
Primary health care system
Services provided within context of peoples' lives
Care is directed toward a specific geographical group
Traditional Acute Care Settings: Nursing Role Benefits
Predictable routine
Maintenance of hospital policy
Predictability of nursing and medical goals
Resource availability
Collegial collaboration and consultation
Controlled client adherence with plan of care; the client takes medicine and treatment on time
St
Community-based Nursing: Client Benefits
Familiar and comfortable environment
Routine that is less determined by the nurse or health profession
Diverse resources, including friends, family, pets, available for support and comfort
Autonomy and choice in health decisions
Effective CBHC Systems
Provides easy access to care
Is flexible in responding to needs
Promotes communication among agencies
Support family caregivers
Is affordable