Basic Nursing: Foundations of Skills & Concepts Chapter 5

1. Basic Nursing: Foundations of Skills & Concepts Chapter 5 THE HEALTH CARE DELIVERY SYSTEM

2. What is the Health Care Delivery System? A mechanism for providing services that meet the health-related needs of individuals.

3. Three levels of Health Care • Primary • Secondary • Tertiary

4. Primary Care • Goal: To decrease the risk to a client (individual or community) of disease or dysfunction. • Approach: General health promotion. Protection against specific illnesses.

5. Secondary Care • Goal: To alleviate disease and prevent further disability. • Approach: Early detection and intervention.

6. Tertiary Care • Goal: To minimize disability associated with chronic or irreversible conditions. • Approach: Restorative and rehabilitative activities to attain optimal level of functioning.

7. The U.S. System Health care services are delivered and financed by three sectors: • The public (official, voluntary, and nonprofit agencies) • Public/private • Private (hospitals, extended-care facilities, hospices, schools, etc.)

8. Hospital Extended-care facilities Home health care agencies Hospices Out-patient settings Schools Industrial Clinics Managed care organizations Community nursing centers Rural primary care hospitals Health Care Settings

9. Health Care Team Members Health care is delivered by a multidisciplinary team, all working together. Examples include: • Physician (MD) • Nurse (RN, LP/VN) • Nurse Assistant (CAN) • Registered Dietician (RD)

10. Economics of Health Care The U.S. health care system has a diverse base: • 32% private insurance • 14.8% medicaid • 18.8% Medicare • 11.8% Other public programs • 17.4% Out of Pocket • 4.5% Other private

11. Private Insurance Model • Basis of U.S. system • Individual pays monthly premiums for coverage and receives access on an as needed basis

12. Managed Care Model • Developed to provide coordinated care with an emphasis on prevention • A system of providing and monitoring care wherein access, cost, and quality are controlled before or during delivery of service

13. HMOs, PPOs and EPOs • Health Maintenance Organizations (HMOs) have a single point of entry. Entry into the health plan through a point designated by the plan. • Preferred Provider Organizations (PPOs) allow individuals to access health care from within a pool of providers. • Exclusive Provider Organizations (EPOs) are similar to PPOs except that care is intended to be delivered exclusively from within the selected pool of providers.

14. Federal Insurance Plans • Medicare: Provides health care coverage for elderly persons and disabled persons. • Medicaid: Federal and Local administered program that provides health care services for the poor.

15. Factors Influencing Health Care • Cost • Access • Quality

16. Cost Issues Many factors influence costs: • An oversupply of specialized providers • A surplus of hospital beds • The passive role assumed by most consumers. • The aging of the population. • The increased number of people with chronic illnesses. • Unnecessary use of services (e.g. additional diagnostic testing) and increase in health-related lawsuits.

17. Access Issues Many factors influence an individuals ability to access the health care system: • Inadequate or cost of insurance • Cultural barriers • Limited access to ancillary services (e.g. child care, transportation) • Certain preexisting conditions making it difficult to obtain insurance • Shortage of providers in rural or inner city areas

18. Quality Issues Many factors influence the quality of care individuals receive: • The litigious environment and response toward defensive practice (e.g. ordering all possible tests). • The widely held American belief that more is better. • Lack of access to and continuity of services result in subsequent misuse of acute services.

19. Challenges The U.S. Healthcare system faces some serious challenges: • Public’s disillusionment with providers • Public’s loss of control over health care decisions • Changes in practice settings • Decreased use of hospitals and related impact on quality of care • Ethical issues • Health care needs of vulnerable populations

20. Nursing’s Responseto the Challenges The nursing profession has responded to the multiple challenges in health care delivery by proposing a plan for reform.

21. Nursing’s Vision for the Future To provide health care services that emphasize PREVENTION and PRIMARY HEALTHCARE for clients, thereby helping to reduce costs and increase the quality of health care