Community-BasedCommunity-Based HealthCare HealthCare

PPP by Marianne McAuley , BSN, MS, RNPPP by Marianne McAuley , BSN, MS, RNRevised KBurger1008Revised KBurger1008

LECTURE # 20 FALL 2009LECTURE # 20 FALL 2009

What is Community-Based What is Community-Based Health Care? Health Care?

Part of holistic nursing practicePart of holistic nursing practice Focuses on primary health interventions Focuses on primary health interventions

– – [ preventative health care ][ preventative health care ]

Considers unique needs of a specific Considers unique needs of a specific geographic region and population of that geographic region and population of that community.community.

Diverse settings – rural, urban, etc. Diverse settings – rural, urban, etc.

HEALTHY PEOPLE 2010HEALTHY PEOPLE 2010

Health care goals for the nationHealth care goals for the nation

– Increase quality & years of healthy life for Increase quality & years of healthy life for AmericansAmericans

– Remove disparities in health careRemove disparities in health care

PUBLIC HEALTH NURSINGPUBLIC HEALTH NURSINGUnderstand needs of a populationUnderstand needs of a population

PUBLIC HEALTH PROBLEMS PUBLIC HEALTH PROBLEMS – Prevalence of overweightPrevalence of overweight– Under immunization of childrenUnder immunization of children– Increase of STD Increase of STD – Drug resistant strains of TBDrug resistant strains of TB– Toxic environmental conditionsToxic environmental conditions– New diseases - AIDS, West Nile VirusNew diseases - AIDS, West Nile Virus

Components of a Components of a Community AssessmentCommunity Assessment

PopulationPopulation– Demographic census dataDemographic census data– Predominant cultural groupPredominant cultural group

StructureStructure– Location of servicesLocation of services– Locations where people congregateLocations where people congregate– HousingHousing– economyeconomy

Social SystemSocial System– Transportation systemTransportation system– Health system – gaps in services?Health system – gaps in services?– GovernmentGovernment

Types of Preventive ServicesTypes of Preventive Services Primary:Primary:

– Decrease risk to a client for diseaseDecrease risk to a client for disease life-style modificationslife-style modifications

Secondary:Secondary:– Early intervention to alleviate diseaseEarly intervention to alleviate disease

Diagnosis & prompt intervention to decrease severity of a Diagnosis & prompt intervention to decrease severity of a diseasedisease

screeningsscreenings

TertiaryTertiary– Minimize effects of chronic conditionsMinimize effects of chronic conditions

rehabilitation activitiesrehabilitation activities

National Public AgenciesNational Public Agencies

U.S. Dept. of Health & Human ServicesU.S. Dept. of Health & Human Services– administratively responsible for public health administratively responsible for public health

care servicescare services

U.S. Public Health ServicesU.S. Public Health Services– oversees delivery of public servicesoversees delivery of public services

Veteran’s AdministrationVeteran’s Administration– health care for members of armed forces health care for members of armed forces

Agencies of USPHSAgencies of USPHS CDCCDC- prevents transmission of communicable - prevents transmission of communicable

diseasesdiseases FDAFDA - Protects public from unsafe drugs, food, - Protects public from unsafe drugs, food,

cosmeticscosmetics NIHNIH – National Institute of Health – National Institute of Health

– conducts research & education for specific diseasesconducts research & education for specific diseases AHRQ AHRQ – Agency for Health Care Research & – Agency for Health Care Research &

QualityQuality– identifies standard of care for high-volume diseasesidentifies standard of care for high-volume diseases

State and Local State and Local Health Departments Health Departments

New York State Department of HealthNew York State Department of Health NYSDOHNYSDOH

Suffolk County Department of HealthSuffolk County Department of Health SCDOH SCDOH

Voluntary AgenciesVoluntary Agencies

ANA, AMAANA, AMA American Heart AssociationAmerican Heart Association American Cancer SocietyAmerican Cancer Society Meals on WheelsMeals on Wheels Support GroupsSupport Groups

ROLES OF THE NURSEROLES OF THE NURSE

CaregiverCaregiver CollaboratorCollaborator AdvocateAdvocate EducatorEducator ManagerManager

– Change agentChange agent

CounselorCounselor

FINANCIAL ASPECTS OF FINANCIAL ASPECTS OF HEALTH CAREHEALTH CARE

US: private insurance modelUS: private insurance model Past: Retrospective System: fee-for-servicePast: Retrospective System: fee-for-service Present: Prospective System: predetermined Present: Prospective System: predetermined

fixed amounts of paymentsfixed amounts of payments Managed CareManaged Care Payment System: 1983: Payment System: 1983: ProspectiveProspective

– Diagnosis Related Groups (DRGs)Diagnosis Related Groups (DRGs)– Length of Stay (LOS)Length of Stay (LOS)

Managed CareManaged Care

access, cost & quality are controlledaccess, cost & quality are controlled emphasis on prevention & primary careemphasis on prevention & primary care not a place, but an organizational not a place, but an organizational

structurestructure primary care physician - gatekeeperprimary care physician - gatekeeper

Types of Managed CareTypes of Managed Care

Managed Care Organizations (MCO)Managed Care Organizations (MCO)

-- Staff model = physicians employed by Staff model = physicians employed by the MCOthe MCO

-- Group, Network, Independent model = Group, Network, Independent model = MCO contracts with specific practitioners MCO contracts with specific practitioners or groupsor groups– capitated rates: a preset flat fee based on capitated rates: a preset flat fee based on

membership not servicesmembership not services– referral needed for specialistsreferral needed for specialists

TYPES OF MANAGED CARETYPES OF MANAGED CARE

PPO [ Preferred Provider Organization ]PPO [ Preferred Provider Organization ] - members use network of providers- members use network of providers - insurance plans and self-insured - insurance plans and self-insured

employersemployers

– members pay extra for providers outside of members pay extra for providers outside of networknetwork

– incentive for providers: large # of patientsincentive for providers: large # of patients– 42% growth rate in last 10 years42% growth rate in last 10 years

MEDICAREMEDICARE A type of MCOA type of MCO Part A:Part A: inpatient hospital, skilled nursing inpatient hospital, skilled nursing

facility, home, hospice care facility, home, hospice care – no premium - paid by Federal gov’tno premium - paid by Federal gov’t

Part B:Part B: outpatient costs, physician visits outpatient costs, physician visits– paid by monthly premium paid by monthly premium

Part D: [ as of 1/06] prescription coverage Part D: [ as of 1/06] prescription coverage Part D: [ as of 1/06] prescription coveragePart D: [ as of 1/06] prescription coverage

MEDICAIDMEDICAID

For people with low incomeFor people with low income Jointly administered by Federal Jointly administered by Federal

government & statesgovernment & states Each state determines eligibility & Each state determines eligibility &

services services 90% of long-term care (nursing centers) 90% of long-term care (nursing centers)

paid by Medicaidpaid by Medicaid

ISSUES IN HEALTH CAREISSUES IN HEALTH CARE

CostCost– oversupply of specialized providersoversupply of specialized providers– focus on treatment of disease, not preventionfocus on treatment of disease, not prevention– surplus of hospital bedssurplus of hospital beds– consumers are passiveconsumers are passive– aging of populationaging of population– advanced technologyadvanced technology– lawsuitslawsuits

ISSUES IN HEALTH CAREISSUES IN HEALTH CARE

AccessAccess– more likely to develop health problemsmore likely to develop health problems– poorer outcomespoorer outcomes

Vulnerable PopulationsVulnerable Populations--PoorPoor-Homeless-Homeless-Abused-Abused-Substance Dependent-Substance Dependent-Elderly-Elderly-Immigrant -Immigrant -Mentally Ill-Mentally Ill

Proper assessment requires non-judgmental and Proper assessment requires non-judgmental and culturally competent attitudes. Critical thinking!culturally competent attitudes. Critical thinking!