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At the completion of this lecture, the trainee should be able to:

2. 3. 4. 5. 6.

Explain the major forces that influence change in the health care system. State the gaps between client needs and services offered. Outline the various component of the current health care system. Identify the various component of the current health care system. Express strategies professional nurses could use to thrive in the current and future health care delivery system. Explore the ethical issues surrounding current changes in health care delivery.

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One of the most significant influences affecting health care delivery is the increasing population of older people. Other demographic influences include changes in geographic distribution and composition. Good prenatal care can prevent prematurity and low birth weight in infants. Worldwide. Urban midsize cities are experiencing rapid growth in the need for health care delivery services for the very young and the elderly. they can help people in using the system. Humans have control over some and remain powerless against others.FORCES INFLUENCING CHANGES IN THE HEALTH CARE SYSTEM When nurses understand how health care delivery occurs. the population of those older than 65 years is expected to grow from 10% in 1975 to 18% to 20% by 2030. 69771067. Mental health and dental needs also will increase. Chronic disorders such as diabetes and osteoarthritis. Numerous forces influence recent and future changes within the health care system. The increasing need for coordination and continuity of care provides an opportunity for managed care by professional nurses. illness prevention and rehabilitative services are needed to enhance the quality of life for the elderly. cognitive impairment and the increased fragility of advancing age are of major concern. Because older persons often have chronic conditions that require treatment and care. Age-Related Factors The increasing numbers of older adults means a greater need for acute care hospitalization for diseases of the heart. 1. Health promotion. malignant neoplasms and chronic incurable diseases with multisystem failures and functional decline. Developing a health care system that effectively provides access.doc 2 . Older adult caregivers (primarily women) of their frail elderly parents will need support and assistance. Infant mortality continues to be of major concern. their increasing numbers will exert a continuing upward pressure on health care costs. cost and quality seems to be the greatest challenge confronted by the health care system. There is evidence that primary care directed at high-risk mothers can be effective. Health promotion efforts aimed at influencing high-risk behaviors among adolescents are especially needed.

It is estimated that in 2000. A number of therapies have been developed. 3. disability. There will be an increasing need for acute and community care. ENVIRONMENT FACTORS Our industrial age is associated with numerous environmental problems that have an impact on health. in particular. Therapies for once fatal illnesses and injuries are prolonged life. provide essential for prevention. poverty and crime Community health nurses. even longer life spans can be predicted for those with access to these new therapies. As scientific knowledge and technology expand. including: traffic accidents transmission of hiv through contaminated needles lost wages and productivity increased homelessness.2. scientific advances and 69771067. • • • • 4. However. Drug and Alcohol Abuse Abuse of alcohol and other drugs is a causative factor in various severe health and social problems. medical science has focused on expanding the length of the human life span.doc 3 . with 90% them in developing countries (WHO. but no cure is known. detection referral for treatment and education. 2001). an estimated 40 million people worldwide had HIV. education and counseling regarding HIV prevention and nurses will need to lead programs for HIV and other infectious diseases. Impact of HIV Acquired immune deficiency syndrome (AIDS) is now a world pandemic. including: air pollution the greenhouse effect acid rain deforestation increased ultraviolet radiation (associated with depletion of the ozone layer) toxic and nuclear wastes lead-based paints and asbestos • • • • • • • Science and Technology During the 20th Century.

adequate exercise. Clients are becoming more aware of preventive and therapeutic interventions and want mutuality. and controlling the use of abusive substances. Collaborative care has created opportunities for nursing to: distribute information and promote an educated public strengthen nursing’s influence on health promotion promote associations with clients and collaborative relationships with physicians become accepted as primary care providers for long-term care • • • • Declining Enrollment in Nursing Programs In 1994.increased used of technology add to the cost of health care delivery. such as alcohol and other drugs. The decrease in supply is in response to a number of factors including: • • a decrease in the population of people 18 to 24 years of age a shift in interest from a career in nursing 4 69771067. advances in medical therapies are expensive. overall enrollments in basic Registered Nurse Programs in the United States decreased for the first time in 6 years. Changing Attitudes During the last two decades. and need increased health education. chemical and drug dependencies and the predisposition to other diseases. research and noninvasive procedures increases.’ Evidence suggests a shift in attitudes toward personal involvement in choices affecting health status. This decrease is continuing. rather than paternalism. rest and relaxation. People begin to accept increased responsibility for personal health and self-care. the public has become increasingly aware of and interested in promoting health.doc . To prevent illness and promote health. As clients have requested and received information. by health care professionals. Scientific Within the last few years. developing good nutrition. with 1996 enrollment in entry levels bachelor’s programs decreasing 6.2% from the previous year. As informed clients become more involved in health-related decision-making. pharmaceutical firms have begun directly advertising new products to consumers using various media formats. People are more aware of the relationship between lifestyle and the incidence of stress-related disease. people have focused attention on moderating stressful aspects of their lifestyles. they have begun to question the advantage that the ‘the doctor knows best. Pharmaceutical companies expect to profit from newly developed medications. the emphasis on ethics.

Physician Surplus Nursing supply and demand is affected by the supply of physicians. respect from others (especially physicians and administrators) and opportunities for growth and promotion. expansion and advancement. some physicians view advanced practice nurses as competitive providers of health care. There is a growing oversupply of physicians in urban areas and specialties and a shortage in family practice and in rural and impoverished areas.nurses express dissatisfaction with basic working conditions such as scheduling. Physicians have become more active in pension. stating that they are going to leave the profession.• • an increase in the number of career choices available to women (who comprise 97% of the nursing work force) limited salary and promotion increases throughout a nursing career • • image problems. is increasing. Nurses Entrepreneurs Nurses also can assume more control and accountability when they become entrepreneurs.doc 5 . The number of nurses. salaries and limited career financial potential limited return for increased education and low status increased labor intensity of acute illness in hospitals understaffing in acute and extended care facilities • • Jobs Satisfaction among Nurses Job satisfaction is an issue . including an emphasis on hard technical work. inadequate numbers of staff and the correct mix of nursing and support personnel. Nurses also express concern about the profession. The surplus of available physicians will have a significant impact on nursing practice and on other aspects of the health care delivery system. low entry. rather than professional colleagues. elderly ambulatory and community settings that previously were less appealing. Nurse entrepreneurs offers interactive video health education. case 69771067. Unfortunately. Advanced Practice Nursing Some physicians view advanced practice nurses as a threat to medical practice. including control over nursing practice. Registered nurses in advanced nursing practice have the knowledge base and practice experience to prepare them for specialization. adequate autonomy for client care. foot care. aromatherapy. enterostomal therapy. legal consultation. massage.doc 6 . quality assurance. organization reinvention and general health counseling service programs. facility planning.

ALTERNATIVE AMBULATORY CARE SYSTEMS • • • • • • Diagnostic centers Minor emergency Surgery centers Birthing centers Substance abuse facilities Rehabilitation centers Although occupancy rates have been decreasing. ALTERNATIVE DELIVERY SYSTEMS Alternative delivery systems.doc 7 . have developed during the past few years.CHANGES IN THE HEALTH CARE DELIVERY SYSTEM: NURSING IMPLICATIONS STRUCTURE AND ORGANIZATION Health care delivery system provides: Primary care: health promotion prevention of illness treatment toward the cure of illness Secondary care: Tertiary care: technologically complex diagnostic. providing care at a lower cost than is possible through hospital admittance. the severity of illness of clients who are admitted to the hospital has been increasing. alternative structures have been developed recently. Various categories and classifications designate the purpose of health care providing organizations. Although hospitals have been the dominant provider care. 69771067. treatment and rehabilitative service. particularly for ambulatory secondary care.

nurses accommodate for them by selecting from a variety of available nursing care delivery models. These integrated services need to be near an urban health care that offers comprehensive. Factors considered include: • • • acuity level of clients specialized needs of clients availability of registered nurses to meet special care needs numbers of available staff nursing care delivery system used by the health care organization • • When nursing shortages occur.INTEGRATED HEALTH CARE DELIVERY SYSTEMS Health care delivery within the next few years may differ greatly. technological medical therapies and offer complementary therapies. sophisticated. Clients will see nurse practitioners. The requirement will be for a very integrated health care delivery system that provides clients with a high continuity of care. care will be managed and emphasis placed on health promotion. 69771067. physician assistants or primary care physicians for routine health care maintenance whilst clients will see specialists only when advanced diagnostic services or complicated disease management need arise. Under this integrated system. Clients will receive less expensive follow-up care at home or in extended care facilities. NURSING CARE DELIVERY MODELS On a daily basis. nurses make decisions related to organizing and managing client care.doc 8 . Nurses consider a variety of factors when selecting the best way to deliver care to a group of clients.

private duty and intensive care nursing settings. • • Case Method or Total Client Care Nurses assume the responsibilities for meeting the care need of a single client or group of clients. Another nurse assumes the tasks of administering intravenous therapy.doc 9 . Example of functional nursing pattern: • • One professional nurse assumes the role of charge nurse. Functional nursing divides tasks among nursing staff members based on registration and tasks. Currently. nurses use the case method in home. Another nurse receives the assignment to administer oral medications. In Victorian times. case nursing was the only model for care delivery. care becomes fragmented. doing client assessments and documenting care for all clients. who makes staff assignments. Because the least skilled and lowest paid workers assume routine care tasks that require no special skills or license. • • • Functional Nursing Functional nursing developed in response to a nursing shortage in the 1940s. perform treatment such as dressing changes and deliver eneteral feedings. functional nursing promotes efficiency in care delivery. NURSING CARE DELIVERY MODELS • • • • • • • Case Method or Total Clinic Care Functional Nursing Team Nursing District Nursing Client-Focused Care Nursing Interdisciplinary Care Delivery Model Case Management 1. Clients may receive care without regard for their sleep or rest needs.The following is an overview of currently used nursing care delivery models. • • 2. But because of the division of client care tasks. develops client care plans and directs all unit activities. Nursing Instructors assign nursing students using the case method for initial clinical nursing experiences. A nurse aide 69771067.

assumes responsibility for monitoring vital signs and performing hygiene measures for all clients.doc . The goal of client-centered care is to cross-train unlicensed and other ancillary workers to be capable of performing multiple client care functions to improve productivity levels. each team cares for approximately the same number of clients with a similar client acuity. client-focused care or modular nursing. client-focused care. • Team Nursing Team nursing started during the end of World War II in response to the nursing shortage and to fix problems created by the functional nursing care delivery system. In team nursing a group of nursing staff personnel with varying skills and registration status care for the needs of a group of clients. A team of nursing staff would provide care for a limited number of clients on an acute care nursing unit. Extended care facilities. home health agencies and acute care hospital use team nursing. • 5. some nursing experts consider this an interdisciplinary care delivery model. • • Interdisciplinary Care Delivery Model Because the client-centered approach includes more than nursing care. Various terms have been given to the most newly developed nursing care delivery systems. Satellite laboratories also may be present on a unit. Success relies on effective written and verbal communication skills. The team assumes responsibility for the total care given to its assigned client group. Improved efficiency of nursing care delivery has provided the force for the development and implementation of a new care delivery system for acute care settings. Large nursing units may have multiple teams to care for clients. With team nursing. • • • Client-Focused Care Nursing Care delivery systems were redesigned in the 1990’s because of rising costs of acute care facilities. The registered nurse serves as the team leader. • • • • • • • • • 4. satellite pharmacies or unit computerized medication supply units enable professional nurses to acquire ordered mediations immediately. Team conferences are held to discuss the daily nursing care needs for the client group. 3. who divides client care duties for one shift focuses on client needs and supervises team members. such as work redesign. 10 • 69771067. With the client-centered care approach.

and infants with low birth weights. such as the frail elderly. diabetes or multisystem failure.doc .• • • Client care units store client care supplies close to client rooms. may benefit from the service of a nurse case manager. costeffective health care is the main aim. Client populations. • 6. Some institutions keep the client medical record at the bedside or in a holder directly outside the client room. Case management tries to reduce the use of the emergency department for treatment of symptoms of chronic disease because such care is not costeffective and does not provide continuity of care. As hospitals and health care agencies merge as for-profit organizations. 11 69771067. clients with transplants. • Case Management Case management provides a system of client care delivery that focuses on the achievement of outcomes within effective time frames and with appropriate use of resources. The central nursing station is eliminated and client care documentation is done by staff at the bedside or in small nursing stations located in close proximity to client rooms. • • TASKS OF THE CASE MANAGER Assessment: client’s home environment client and family teaching requirement need for long-term treatment and procedures Collect clinical data: health history information physical examination findings Evaluate: needs after discharge abuse of alcohol or drugs referrals after discharge (such as for physical therapy or diabetic education) prescription medicine need for long-term care need for long-lasting medical equipment • The case manager in the acute care setting integrates nursing processes with management processes to achieve client outcomes.

In all settings.• Implementation of the plan of care requires observation and time management. • • • No one single nursing care delivery system model can provide comprehensive. • • • • Cost of Health Care Many changes in society have increased the cost of health care delivery. Team meetings are held to identify the possibility of early discharge to home or the unexpected need for a skilled nursing facility after discharge from the hospital. is coordinated among professionals and ensures economic care but does not compromise quality. The case manager acts as the client’s advocate in getting benefits and services from health care payers. Deviation from expected outcomes may be observed. Clinician Manager Financial communicates effectively with a multidisciplinary health care team. The nurse providing client care reports client progress and abilities during team meetings. 2. This comparison may identify new goals or require goals revision. The case manager monitors the client’s progress in terms of recovery. cost and efficiency of the facility. health care delivery shifted from being an altruistic service to a business. as well as the availability of professional nurses. Some societal changes have contributed to the escalation of health care costs. the nurse manager assumes responsibility for determining the effectiveness of the currently used nursing care delivery system. • • • • • • • • • Evaluation of the client’s progress is compared to the length of stay. Selection of a nursing care delivery system depends on the health care organization’s mission. The case manager assertively coordinates procedures and referrals. • PRIMARY ROLES OF THE CASE MANAGER 1. 3.doc . Professional nurses must exercise care when delegating professional nursing tasks to technical and unlicensed staff members. 12 69771067. identifying trends in the hospitals delivery or performance of services. The client’s progress is compared daily to the goals of the plan of care. Within the past 20 years. client’s care consultants. holistic care of high quality in a cost-effective manner in all health care settings. Any delays or repeated procedures compromise efficient and optimum care. philosophy and values. Most of the time. health care clients rely on health care professionals for sound advice to maximize their health potential. • 7.

equity and quality given available resources. 9. the costs of hospital care have continued to increase. difficult choices must be made. such as magnetic resonance imaging (MRI). The development and intense use of advanced technology was encouraged for medical research. Ethical questions raised by these choices include: 69771067. coronary bypass grafts and computed tomography (CT) scans did in earlier years. by procedures performed to avoid the threat of a lawsuit and by excessive lengths of stay. • • • • • • • • Hospital Costs Hospital costs have been a major component of increasing health care costs. New technologies. Specialization of knowledge promoted the growth of medical specialties supported by a complex network of nonphysician health care workers. Health care expenditures fall into the following categories: 1. Because it is not possible to meet all goals of accessibility. physicians and third-party reimbursers urged consumers to expect extensive use of hospital resources for diagnosis and treatment. 10. Several factors have influenced hospital costs. Inflation in health care costs also has increased at a rate higher than that of general inflation. 2. long-term dialysis.8. In the past. Of the personal health care services. One basic issue is the relative valuing of predictability and containment of the costs of health care versus the access to health care for all persons. • • Economic Forces In this century health care costs have rapidly increased. hospital costs constitute the greatest single health care expense. health-related research and facilities construction payment for personal health care services and supplies • • Payment for individual health care services and supplies costs more than new construction or research. the artificial heart. Sometimes hospital admittances were unnecessary. genetic engineering. • • • Ethical Concerns Ethical concerns have been raised by an increasing life span. costs were increased by multiple unnecessary laboratory tests.doc 13 . monoclonal antibodies for the treatment of cancer and organ transplantation. just as hip replacement. Although these practices have been changing. create pressures on health care costs. the development of health care technology and the increasing cost of delivering care.

economic.1. shape and direction of the health care system. who should have priority? What is an acceptable level of health care? Should technology be available to all. regardless of cost or should it be rationed? What should be the criteria for rationing? Who should determine the criteria? How much is the prolongation of life worth? Does reducing costs reduce the quality of care? What rights do clients have? Is cure of all disease possible? Is cure of all disease desirable at any cost? It is critical that the voice of the nursing profession be added to that of the public in discussions of the philosophic considerations and values that will shape the decision concerning the size. 8. Who will cover the costs to make the system affordable. 7. 10. 69771067. The nursing professional has the opportunity to influence the direction of change to ensure the improvement of health and health care.doc 14 . attitudinal and available manpower forces. 2. raising multiple ethical considerations. 9. acceptable and available to all? How much is health care a basic right? If there are limits on access to health care. the health care delivery system is in the process of structural change and reorganization. 4. 5. 12. CONCLUSION As a result of significant demographic. 11. 3. 6. Health care providers can use historical events to prevent repeating past mistakes.