the health care delivery system chapter 2 nur 215 professor stewart

The Health CareThe Health CareDelivery SystemDelivery System

Chapter 2Chapter 2

NUR 215NUR 215

Professor StewartProfessor Stewart

Copyright by Delmar, a division of Copyright by Delmar, a division of Thomson LearningThomson Learning

22

What is a Health Care What is a Health Care Delivery System?Delivery System?

It is a mechanism for providing services It is a mechanism for providing services that meet the health-related needs of that meet the health-related needs of individuals.individuals.

Nursing is a major component of the U.S. Nursing is a major component of the U.S. health care delivery system.health care delivery system.


33

Organizational FrameworkOrganizational Framework

Public Sector (includes official and Public Sector (includes official and voluntary)voluntary)

Private SectorPrivate Sector

No single agency or group controls the No single agency or group controls the entire health care system.entire health care system.


44

Federal Level (DHHS)

State Level (Dept. of Health)

Local Level Health Units

Commun-icable

Disease Control

Health Records Mainten-

ance (Vital Statistics)

Individual Health

Services

Environ-mental Health

and Safety

Public SectorPublic Sector

Public Health

Education


55

Private SectorPrivate Sector

Largest segment of the health care Largest segment of the health care system (most healthcare facilities are run system (most healthcare facilities are run by private for-profit or not-for-profit by private for-profit or not-for-profit corporations)corporations)

Also includes health insurance industry, Also includes health insurance industry, pharmaceutical companies, suppliers of pharmaceutical companies, suppliers of health care technology and equipmenthealth care technology and equipment


66

Reimbursement MethodsReimbursement Methods

Private InsurancePrivate Insurance Managed CareManaged Care

Health Maintenance Organizations (HMOs)Health Maintenance Organizations (HMOs) Preferred Provider Organization (PPO)Preferred Provider Organization (PPO)

Federal government insuranceFederal government insurance plansplans MedicareMedicare MedicaidMedicaid


77

Managed CareManaged Care

Goal: The delivery of services in the Goal: The delivery of services in the most cost-efficient manner possible. most cost-efficient manner possible.

Seeks to control costs by monitoring Seeks to control costs by monitoring delivery of services and restricting delivery of services and restricting access to expensive procedures and access to expensive procedures and providers.providers.


88

Managed Care (cont.)Managed Care (cont.)

Health Maintenance Organizations Health Maintenance Organizations (HMOs) (HMOs) Capitated RatesCapitated Rates Primary care providers (“Gate-keepers”)Primary care providers (“Gate-keepers”)

Preferred Provider Organizations (PPO)Preferred Provider Organizations (PPO) NetworksNetworks


99

Federal Government PlansFederal Government Plans

Medicare – for older adults and people Medicare – for older adults and people with disabilitieswith disabilities Diagnosis-related groups (DRGs)Diagnosis-related groups (DRGs)

Medicaid – For the economically Medicaid – For the economically disadvantageddisadvantaged


1010

Health Care TodayHealth Care Today

Primary Care Provider LimitationsPrimary Care Provider Limitations ReferralsReferrals Decreased HospitalizationDecreased Hospitalization Care at HomeCare at Home Less Service Oriented and More Less Service Oriented and More

Business OrientedBusiness Oriented

Is health care aIs health care aright or a privilege?right or a privilege?


1212

Levels of Health CareLevels of Health Care

PrimaryPrimary

SecondarySecondary

TertiaryTertiary


1313

Primary CarePrimary Care

Goal – To decrease the risk to client for Goal – To decrease the risk to client for disease or dysfunctiondisease or dysfunction

Focus – General Health Promotion; Focus – General Health Promotion; Protection against specific illnessesProtection against specific illnesses

Examples: Teaching, Lifestyle Examples: Teaching, Lifestyle Promotion, ImmunizationsPromotion, Immunizations


1414

Primary Care SettingsPrimary Care Settings

School health servicesSchool health services Occupational health servicesOccupational health services Physicians’ officesPhysicians’ offices ClinicsClinics Nursing centersNursing centers Block and parish nursingBlock and parish nursing


1515

Secondary CareSecondary Care

Goal: Early intervention to alleviate Goal: Early intervention to alleviate disease and prevent further disabilitydisease and prevent further disability

Focus: Early detection and interventionFocus: Early detection and intervention

Examples: Screening, diagnosis, acute Examples: Screening, diagnosis, acute care, surgerycare, surgery


1616

Secondary SettingsSecondary Settings

Hospitals/medical centersHospitals/medical centers Emergency departmentsEmergency departments Medical unitsMedical units Intensive care Intensive care

Psychiatric facilitiesPsychiatric facilities Rural hospitalsRural hospitals


1717

Tertiary CareTertiary Care

Goal: To minimize effects of and permanent Goal: To minimize effects of and permanent disability due to chronic or irreversible disability due to chronic or irreversible conditioncondition

Focus: To restore and rehabilitate to obtain Focus: To restore and rehabilitate to obtain optimal level of functionoptimal level of function

Examples: Education and retraining; Examples: Education and retraining; Environmental modificationsEnvironmental modifications


1818

Tertiary Care SettingsTertiary Care Settings

Home health careHome health care Rehabilitation centersRehabilitation centers Extended care facilitiesExtended care facilities


1919

Health Care TeamHealth Care Team

Nurse (RN)Nurse (RN) Physician (MD, DO)Physician (MD, DO) Physician assistant (PA)Physician assistant (PA) Pharmacist (RPh)Pharmacist (RPh) Dentist (DDS, DMD)Dentist (DDS, DMD) Dietitian (RD)Dietitian (RD) Social worker (SW)Social worker (SW)

Respiratory therapist Respiratory therapist (RT)(RT)

Physical therapist (PT)Physical therapist (PT) Occupational therapist Occupational therapist

(OT)(OT) ChaplainChaplain Unlicensed assistive Unlicensed assistive

personnel (UAP)personnel (UAP)


2020

Roles of the NurseRoles of the Nurse

CaregiverCaregiver TeacherTeacher AdvocateAdvocate ManagerManager ExpertExpert Case managerCase manager Team memberTeam member


2121

Nurses and the Health Care Nurses and the Health Care TeamTeam

Nurses usually coordinate the care Nurses usually coordinate the care provided by a multidisciplinary teamprovided by a multidisciplinary team

The nurse is always accountable for the The nurse is always accountable for the overall nursing care of the client.overall nursing care of the client.


2222

DelegationDelegation

Designed to make the work of client care Designed to make the work of client care more efficientmore efficient

May delegate to an LPN or unlicensed May delegate to an LPN or unlicensed assistive personnel (certified nurses aide, assistive personnel (certified nurses aide, personal care assistant, nursing personal care assistant, nursing assistant)assistant)


2323

Factors Influencing the Factors Influencing the Delivery of Health CareDelivery of Health Care

CostCost AccessAccess QualityQuality


2424

CostCost

Factors contributing to the increase in Factors contributing to the increase in cost of health carecost of health care An aging populationAn aging population Technological advancesTechnological advances Surplus of hospital bedsSurplus of hospital beds Increased number of people with chronic Increased number of people with chronic

illnessillness Increase in health related lawsuitsIncrease in health related lawsuits


2525

AccessAccess - - Limiting FactorsLimiting Factors

Inability to obtain insurance (due to high cost, Inability to obtain insurance (due to high cost, pre-existing conditions, or no provision for pre-existing conditions, or no provision for insurance)insurance)

Cultural barriersCultural barriers Shortages of health care providers (esp. in Shortages of health care providers (esp. in

rural areas)rural areas) Limited access to services (due to lack of Limited access to services (due to lack of

transportation, childcare issues)transportation, childcare issues)


2626

QualityQuality

Estimated that 30%-40% of diagnostic/medical Estimated that 30%-40% of diagnostic/medical procedures performed in U.S. are unnecessaryprocedures performed in U.S. are unnecessary

Inappropriate use of resources due to:Inappropriate use of resources due to: Litigious environment that creates tendency toward Litigious environment that creates tendency toward

defensive practice.defensive practice. Resource consumption (belief that more is better)Resource consumption (belief that more is better) Lack of access to and continuity of services with Lack of access to and continuity of services with

subsequent misuse of acute care servicessubsequent misuse of acute care services

Quality frequently compromised by substitution Quality frequently compromised by substitution of UAP for RNsof UAP for RNs

Case StudiesCase Studies


2828

Challenges Within the Challenges Within the Health Care SystemHealth Care System

Disillusionment with professionalsDisillusionment with professionals Loss of ControlLoss of Control Decreased Hospital UseDecreased Hospital Use Changing Practice SettingsChanging Practice Settings Ethical IssuesEthical Issues


2929

Nursing’s Response to Nursing’s Response to Health Care ChallengesHealth Care Challenges

Nursing’s Agenda for Health Care Nursing’s Agenda for Health Care ReformReform

Advanced practiceAdvanced practice Public healthPublic health

the health care delivery system chapter 2 nur 215 professor stewart

Documents