Challenges and Innovations in the Health Care Delivery System

1. Chapter 2 The Health Care Delivery System

2. Challenges to Health Care • Reducing health care costs while maintaining high-quality care for patients • Improving access and coverage for more people • Encouraging healthy behaviors • Earlier hospital discharges result in more patients needing nursing homes or home care.

3. Emphasis on Population Wellness • Health Services Pyramid • Managing health instead of illness • Emphasis on wellness • Injury prevention programs {Fig 2-1 here}

4. National Priorities Partnership • National Priorities: • Patient and family engagement • Population health • Safety/eliminating errors as possible • Care coordination • Palliative care for advanced illnesses • Overuse/reducing waste

5. Institute of Medicine (IOM) • Nurses need to be transformed by: • Practicing to the full extent of their education and training • Achieving higher levels of education and training through an improved education system that provides seamless progression • Becoming full partners, with physicians and other providers, in redesigning the health care system • Improving data collection and the information infrastructure for effective workforce planning and policy making

6. Case Study • Amy Sue Reilly is a 15-year-old white female of Irish descent. She is a freshman at a Catholic high school. Although her parents are divorced, Amy Sue reports that her family (she has two brothers and lives with her mother) is very close, and that her parents work together to meet all their children’s needs. • Amy Sue has had asthma since she was 5 years old. She has been able to control her asthma by taking oral medications and by using inhalers when needed.

7. Health Care Regulation and Competition • Regulatory and competitive approaches • Professional standards review organizations (PSROs) • Created to review the quality, quantity, and cost of hospital care provided through Medicare and Medicaid • Utilization review committees (URs) • Review admissions, diagnostic testing, and treatments provided by physicians who cared for patients receiving Medicare

8. Health Care Regulation and Competition (cont’d) • Prospective payment system (PPS) • Diagnosis-related groups (DRGs) • Capitation • Resource utilization groups (RUGs) • Profitability • Managed care

9. Health Care Regulation and Competition (cont’d) • Patient Protection and Affordable Care Act • Access to health care for all • Reducing costs • Improving quality • Provisions include • Insurance industry reforms • Increased funding for community health centers • Increased primary care services • Improved coverage for children

10. Health Care Settings and Services

11. Health Care Accreditation/ Certification • Reasons: • To demonstrate quality and safety • To evaluate performance, identify problems, and develop solutions • Accreditation earned by the entire organization • Specific programs or services within an organization earn certifications. • The Joint Commission and others

12. Preventive and Primary Health Care

13. Secondary and Tertiary Care • Also called acute care • Focus: Diagnosis and treatment of disease • Disease management is the most common and expensive service of the health care delivery system. • 20% require 80% of health care spending. • Fastest growing age group of uninsured? • Postponement of care by uninsured

14. Secondary and Tertiary Care (cont’d) • Settings • Resource efficiency, word redesign • Discharge planning—nurses’ role

15. Restorative Care • Serves patients recovering from an acute or chronic illness/disability • Helps individuals regain maximal function and enhance quality of life • Promotes patient independence and self-care abilities • Requires multidisciplinary approach • Settings:

16. Restorative Care: Home Care • Provision of medically related professional and paraprofessional services and equipment to patients and families in their homes for health maintenance, education, illness prevention, diagnosis and treatment of disease, palliation, and rehabilitation • Involves coordination of services • Focuses on patient and family independence • Usually reimbursed by government (such as Medicare and Medicaid in the United States), private insurance, and private pay sources

17. Restorative Care: Rehabilitation • Focus: To restore patients to their fullest physical, mental, social, vocational, and economic potential • Includes physical, occupational, and speech therapy, as well as social services • Occurs in many health care settings, both inpatient and outpatient

18. Restorative Care: Extended Care • Extended care facility • Provides intermediate medical, nursing, or custodial care for patients recovering from acute illness or disabilities • Skilled nursing facility (intermediate care) • Provides care for patients until they can return to their community or residential care location

19. Continuing Care • For people who are disabled, functionally dependent, or suffering a terminal disease • Available within institutional settings or in the home:

20. Continuing Care: Nursing Centers or Facilities • Provide 24-hour intermediate and custodial care • Nursing, rehabilitation, diet, social, recreational, and religious services • Residents of any age with chronic or debilitating illness • Regulated by standards: Omnibus Budget Reconciliation Act of 1987 • Interdisciplinary functional assessment is the focus of clinical practice: MDS, RAIs

21. Continuing Care: Assisted Living

22. Respite Care • The service provides short-term relief or “time off” for persons providing home care to an ill, disabled, or frail older adult. • Settings include home, day care, or health care institution with overnight care. • Trained volunteers allow family caregivers to leave the home for errands or social time.

23. Quick Quiz! 1. A patient who needs nursing and rehabilitation following a stroke would most benefit from receiving care at a A. Primary care center. B. Restorative care setting. C. Assisted-living center. D. Respite center.

24. Adult Day Care Centers • Provide a variety of health and social services to specific patient populations who live alone or with family in the community • May be associated with a hospital or nursing home or may operate independently • Offer services to patients such as daily physical rehabilitation and counseling

25. Hospice • Family-centered care that allows patients to live and remain at home • Focuses on palliative (not curative) care: comfort, independence, and dignity • Provides patient and family support during terminal illness and time of death • Many hospice programs provide respite care, which is important in maintaining the health of the primary caregiver and family.

26. Case Study (cont’d) • Recently, Amy Sue has had some difficulty breathing, especially during gym class. • Corrine is a 45-year-old African American nurse, who recently accepted a job as a school nurse for the four Catholic schools in the area. Three of the schools are grade schools, and one is Amy Sue’s high school. Before she took this job, Corrine worked at a pediatrician’s office.

27. Issues in Health Care Delivery • Nursing shortage • Competency • Evidence-based practice • Quality and safety in health care/ Patient-centered care • Health care organizations are being evaluated on the basis of outcomes such as prevention of complications, patients’ functional outcomes, and patient satisfaction.

28. Issues in Health Care Delivery (cont’d) • Magnet Recognition Program • Nursing-sensitive outcomes • Nursing informatics and technological advancements • Globalization of health care

29. Case Study (cont’d) • Amy Sue’s difficulty managing her asthma is significant for Corrine because Corrine’s oldest daughter has asthma. • In addition, because of her job in the pediatrician’s office, Corrine has had experience with caring for children with asthma and with helping patients access the health care delivery system.

30. Quick Quiz! 2. Technological advances in health care A. Make the nurse’s job easier. B. Depersonalize bedside patient care. C. Threaten the integrity of the health care industry. D. Do not replace sound personal judgment.

31. The Future of Health Care • Change opens up opportunities for improvement. • Health care delivery systems need to address the needs of the uninsured and the underserved. • Health care organizations are striving to become better prepared to deal with these and other challenges in health care. • The solutions necessary to improve the quality of health care depend largely on the active participation of nurses.