The Health Care Delivery System

Chapter 2

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Health Care Delivery System?

Mechanism for providing services that meet the health-related needs of individuals.

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

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Types of Health Care Services

Primary: Health promotion and illness prevention

Secondary: Diagnosis and treatment Tertiary: Rehabilitation

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Three Levels of Prevention

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Health Care Settings Public Sector

Federal Level• U.S. Department of Health and Human

Services (DHHS)

State Level• Department of Health

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Health Care Settings Public Sector

Local Level Health Units• Communicable disease control• Health records maintenance• Individual health services• Environmental health and safety• Public health education

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Public Health Sector of Health Care Delivery

Communicable Disease Control

Health Records Maintenance

(Vital Statistics)

Individual Health Services (e.g. Maternal-Child Health Programs)

Environmental Health and

Safety

Public Health Education

Federal LevelU.S. Department of Health and Human Services (DHHS)

State LevelDepartment of Health

Local LevelHealth Units

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Health Care Settings Private Sector

Hospitals Extended care facilities Home health agencies Hospices Outpatient settings

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Health Care Settings Private Sector

Schools Industrial clinics Managed care organizations Community nursing centers Rural primary care hospitals

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Health Care Team

Nurse (RN) Physician (MD) Physician Assistant (PA) Pharmacist (RPh) Dentist (DDS) Dietitian (RD) Social Worker (SW)

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Health Care Team

Respiratory Therapist (RT) Physical therapist (PT) Occupational Therapist (OT) Chaplain Unlicensed Assistive Personnel (UAP) Dental Hygienist

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Advanced Practice Registered Nurse

Diagnoses and manages common health problems.

Performs medical procedures (e.g., suturing, casting).

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Nursing Roles

Caregiver Teacher Advocate Manager Expert Case Manager Team Member

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Roles of the Nurse

Caregiver Teacher Advocate Manager Expert Case Manager Team Member

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Economics of Health Care

Private Insurance Managed Care

• Primary care providers• Health Maintenance Organizations (HMOs)• Preferred Provider Organizations (PPOs)• Exclusive Provider Organizations (EPOs)

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Economics of Health Care

Federal Government Insurance Plans• Social Security Act 1965• Medicare and Medicaid• Regulated by Centers for Medicare &

Medicaid Services (CMS)

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Federal Government Insurance Plans

Medicare• Individuals over age 65• Public funding• Permanently disabled individuals• Individuals with end-stage renal disease

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Federal Government Insurance Plans

Medicaid• Medically indigent• Determined by federal and state

governments• Inpatient and outpatient hospital services• Physician services• Laboratory services• Rural health clinic services

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Economics of Health Care

Canadian Health Insurance• National health insurance• Single-payer model• Short and long-term care• Financed with tax dollars

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Factors Influencing the Delivery of Health Care

Cost Access Quality

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Cost

Four major factors increase the cost of health care• An over supply of specialized providers• A surplus of hospital beds• The passive role assumed by most

consumers• Inequitable financing of services

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AccessLimiting Factors

Prohibitive costs for employer to provide Inability to obtain individual insurance Cultural barriers Persons with preexisting conditions Shortages of health care providers Limited access to ancillary services

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Quality

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

Inappropriate use of resources A 2002 study revealed that 73% of

nurses surveyed stated that the quality of care at their hospital had declined due to cost-containment measures.

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Challenges Within the Health Care System

Positive Perception of Nurses• Nurses are persistently seen as having the

highest standards of honesty and ethics.• The public believes that if nurses were

allowed to use their skills, they would significantly enhance quality and reduce costs.

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Challenges Within the Health Care System

Nursing shortage Loss of control over health care decisions Decreased use of hospitals Changing practice settings Ethical issues Vulnerable populations

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Challenges Within the Health Care System

Nursing Shortage: By 2020 the workforce is forecast to be 20% below requirements.• Fewer people entering the profession• Aging of the nursing population• Other career options offering greater

remuneration

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Challenges Within the Health Care System

Loss of Control• Consumers express a loss of personal

control within the health care system.• Some feel terrorized by the system.• Many American workers state that their

greatest concern is the possible loss of health care coverage.

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Challenges Within the Health Care System

Decreased use of hospitals• Shorter lengths of stay• Technologic advances• Greater availability of outpatient facilities• More services available in outpatient

settings• Expectations/demands of third-party payers

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Challenges Within the Health Care System

Changing Practice Settings• Most nurses currently practice in hospitals

and will continue to do so in the future.• There is an ever-increasing need for

expanded services and settings.• Larger numbers of nurses will be needed for

primary care, public health, extended care facilities, and the home setting.

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Home Health Nursing

The percentage of home health nurses is increasing in numbers, as health care reform places more nurses (as this home health nurse) outside the acute care setting.

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Challenges Within the Health Care System

Ethical Issues• At present, citizens’ needs are greater than

available resources. • The United States is struggling with major

ethical conflicts over allocation of scarce resources versus compassionate quality care.

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Challenges Within the Health Care System

Nurses continue to advocate for ethical distribution of resources as health care reform progresses.

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Challenges Within the Health Care System

Vulnerable Populations• Children• The elderly• People with AIDS• The homeless• Others living in poverty

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Vulnerable Populations

Children • Children are more likely to be insured than

adults.• One in five children lives in a family with an

income below the poverty level.• The State Children’s Health Insurance

Program was passed in 1997 to expand health insurance coverage to uninsured low income children.

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Vulnerable Populations

The Elderly• A large number of elderly people live in rural

areas.• Many elderly have no health insurance.• Many hospitals in rural areas have been

closed due to economic pressures.

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Vulnerable Populations

People with AIDS• Over 300,000 Americans have been

diagnosed with AIDS.• Approximately 800,000 Americans are

infected with HIV.• The most rapid spread of the disease is

occurring among women, children, and IV drug users and their sexual partners.

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Nursing’s Response to Health Care Challenges

Nursing’s Agenda for the Future is a plan that focuses on strategies to improve professional conditions for nurses and quality of health care by 2010.

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Ten Focus Areas of Nursing’s Agenda for the Future

Leadership and planning

Delivery systems Legislation/

regulationpolicy Professional/nursing

culture Recruitment/

retention

Economic value Work environment Public relations/

communication Education Diversity

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Nursing’s Response to Health Care Challenges

Standards of care Advanced practice Public versus private programs Public health Community health School nursing Long-term care