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.
Copyright by Delmar, a division of Copyright by Delmar, a division of Thomson LearningThomson Learning
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.
Copyright by Delmar, a division of Copyright by Delmar, a division of Thomson LearningThomson Learning
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
Copyright by Delmar, a division of Copyright by Delmar, a division of Thomson LearningThomson Learning
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
Copyright by Delmar, a division of Copyright by Delmar, a division of Thomson LearningThomson Learning
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
Copyright by Delmar, a division of Copyright by Delmar, a division of Thomson LearningThomson Learning
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.
Copyright by Delmar, a division of Copyright by Delmar, a division of Thomson LearningThomson Learning
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
Copyright by Delmar, a division of Copyright by Delmar, a division of Thomson LearningThomson Learning
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
Copyright by Delmar, a division of Copyright by Delmar, a division of Thomson LearningThomson Learning
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?
Copyright by Delmar, a division of Copyright by Delmar, a division of Thomson LearningThomson Learning
1212
Levels of Health CareLevels of Health Care
PrimaryPrimary
SecondarySecondary
TertiaryTertiary
Copyright by Delmar, a division of Copyright by Delmar, a division of Thomson LearningThomson Learning
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
Copyright by Delmar, a division of Copyright by Delmar, a division of Thomson LearningThomson Learning
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
Copyright by Delmar, a division of Copyright by Delmar, a division of Thomson LearningThomson Learning
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
Copyright by Delmar, a division of Copyright by Delmar, a division of Thomson LearningThomson Learning
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
Copyright by Delmar, a division of Copyright by Delmar, a division of Thomson LearningThomson Learning
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
Copyright by Delmar, a division of Copyright by Delmar, a division of Thomson LearningThomson Learning
1818
Tertiary Care SettingsTertiary Care Settings
Home health careHome health care Rehabilitation centersRehabilitation centers Extended care facilitiesExtended care facilities
Copyright by Delmar, a division of Copyright by Delmar, a division of Thomson LearningThomson Learning
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)
Copyright by Delmar, a division of Copyright by Delmar, a division of Thomson LearningThomson Learning
2020
Roles of the NurseRoles of the Nurse
CaregiverCaregiver TeacherTeacher AdvocateAdvocate ManagerManager ExpertExpert Case managerCase manager Team memberTeam member
Copyright by Delmar, a division of Copyright by Delmar, a division of Thomson LearningThomson Learning
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.
Copyright by Delmar, a division of Copyright by Delmar, a division of Thomson LearningThomson Learning
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)
Copyright by Delmar, a division of Copyright by Delmar, a division of Thomson LearningThomson Learning
2323
Factors Influencing the Factors Influencing the Delivery of Health CareDelivery of Health Care
CostCost AccessAccess QualityQuality
Copyright by Delmar, a division of Copyright by Delmar, a division of Thomson LearningThomson Learning
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
Copyright by Delmar, a division of Copyright by Delmar, a division of Thomson LearningThomson Learning
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)
Copyright by Delmar, a division of Copyright by Delmar, a division of Thomson LearningThomson Learning
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
Copyright by Delmar, a division of Copyright by Delmar, a division of Thomson LearningThomson Learning
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
Copyright by Delmar, a division of Copyright by Delmar, a division of Thomson LearningThomson Learning
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