Chapter 2

The Health Care Delivery

System

Copyright © 2017, Elsevier Inc. All Rights Reserved.

 Challenges to Health Care

 Uninsured patients
 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

Copyright © 2017, Elsevier Inc. All Rights Reserved. 2

 National Priorities Partnership

 Promote best practices

 Promote prevention, treatment, and intervention
practices for the leading causes of mortality
 Ensure person- and family-centered care
 Make care safer
 Promote communication and care coordination
 Make quality care affordable

Copyright © 2017, Elsevier Inc. All Rights Reserved. 3

 Institute of Medicine (IOM)

 Nurses need to be transformed by:

 Practicing to the full extent of their training
 Achieving higher levels of education through an
education system that provides seamless progression
 Becoming full partners with physicians and other
health care providers in redesigning the health care
system
 Improving data collection and the information
infrastructure for effective workforce planning and
policy making

Copyright © 2017, Elsevier Inc. All Rights Reserved. 4

 Health Care Regulation and Reform

 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 (UR) committees
• Review admissions, diagnostic testing, and treatments
ordered by physicians who cared for patients receiving
Medicare

Copyright © 2017, Elsevier Inc. All Rights Reserved. 5

 Health Care Regulation and Reform
(Cont.)
 Prospective payment system (PPS)
 Diagnosis-related groups (DRGs)
 Capitation
 RUGs
 Profitability
 Managed care
 “Never Events”

Copyright © 2017, Elsevier Inc. All Rights Reserved. 6

 Health Care Regulation and Reform
(Cont.)
 Patient Protection and Affordable Care Act
 Access to health care for all
 Reducing costs
 Improving quality
 Provisions include
• Insurance industry reforms
• Increased funding for public programs
• Improved coverage for children

Copyright © 2017, Elsevier Inc. All Rights Reserved. 7

 Emphasis on Population Wellness

 Health Services
Pyramid
 Managing health
instead of illness
 Emphasis on
wellness
 Injury-prevention
programs

Copyright © 2017, Elsevier Inc. All Rights Reserved. 8

 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 controls her asthma by taking oral
medications and by using inhalers as needed.

Copyright © 2017, Elsevier Inc. All Rights Reserved. 9

Health Care Settings and Services

1. Preventive 2. Primary

3. Secondary 4. Tertiary

5. Restorative 6. Continuing

Copyright © 2017, Elsevier Inc. All Rights Reserved. 10

 Preventive and Primary Health Care

 Preventive Care
 Reduces and controls risk factors for disease
 Primary care
 Focuses on improved health outcomes
 Requires collaboration
 Health promotion programs lower overall costs
 Reduces incidence of disease
 Minimizes complications
 Reduces the need for more expensive resources

Copyright © 2017, Elsevier Inc. All Rights Reserved. 11

 Secondary and Tertiary Care

 Focus: Diagnosis and treatment of disease

 Disease management is the most common and
expensive service of the health care delivery
system
 Postponement of care by uninsured contributes
to high costs

Copyright © 2017, Elsevier Inc. All Rights Reserved. 12

 Secondary and Tertiary Care (Cont.)

 Hospitals
 Work redesign
 Discharge planning

 Intensive care
 Psychiatric facilities
 Rural hospitals

Copyright © 2017, Elsevier Inc. All Rights Reserved. 13

 Restorative Care

 Serves patients recovering from an acute or

chronic illness/disability
 Helps individuals regain maximal function and
enhance quality of life

Copyright © 2017, Elsevier Inc. All Rights Reserved. 14

 Restorative Care: Home Health Care

 Provision of medically related 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.
Copyright © 2017, Elsevier Inc. All Rights Reserved. 15
 Restorative Care: Rehabilitation

 Includes physical, occupational, and speech

therapy, and social services
 Begins on admission
 Focuses on preventing complications
 Maximizes patient function and independence

Copyright © 2017, Elsevier Inc. All Rights Reserved. 16

 Restorative Care: Extended Care

 Extended care facility

 Provides intermediate medical, nursing, or custodial
care for patients recovering from acute illness or
disabilities
 Intermediate care/skilled nursing facility
 Provides care for patients until they can return to their
community or residential care location

Copyright © 2017, Elsevier Inc. All Rights Reserved. 17

 Continuing Care

 For people who are disabled, functionally

dependent, or suffering a terminal disease
 Available within institutional settings or in the
home:
 Nursing centers or facilities
 Assisted living
 Respite care
 Adult day care centers
 Hospice

Copyright © 2017, Elsevier Inc. All Rights Reserved. 18

 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

Copyright © 2017, Elsevier Inc. All Rights Reserved. 19

 Continuing Care: Assisted Living

 Long-term care
setting
 Home environment
 Greater resident
autonomy
 No fee caps

Copyright © 2017, Elsevier Inc. All Rights Reserved. 20

 Continuing Care: Respite Care

 Respite care provides short-term relief or “time

off” for people providing home care to an
individual who is ill, disabled, or frail.
 Settings include home, day care, or health care
institution with overnight care.
 Trained volunteers enable family caregivers to
leave the home for errands or social time.

Copyright © 2017, Elsevier Inc. All Rights Reserved. 21

 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.

Copyright © 2017, Elsevier Inc. All Rights Reserved. 22

 Continuing Care: 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

Copyright © 2017, Elsevier Inc. All Rights Reserved. 23

 Continuing Care: Hospice

 Family centered care that allows patients to live

with comfort, independence, and dignity while
easing the pains of terminal illness.
 Focuses on palliative (not curative) care
 Many hospice programs provide respite care,
which is important in maintaining the health of
the primary caregiver and family.

Copyright © 2017, Elsevier Inc. All Rights Reserved. 24

 Care Coordination

 Accountable care organizations (ACOs)

 Developed to coordinate medical care
 Nurses act as leaders and care coordinators

 Patient-centered medical home (PCMH)

 Coordinates care, gathers clinical data, monitors
patient outcomes
 Primary care providers function as the hub of the
PCMH

Copyright © 2017, Elsevier Inc. All Rights Reserved. 25

 Case Study (Cont.)

 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.

Copyright © 2017, Elsevier Inc. All Rights Reserved. 26

 Case Study (Cont.)

 Amy Sue’s difficulty managing

her asthma is significant for
Corrine because Corrine’s
oldest daughter has asthma.
 Plus, 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.

Copyright © 2017, Elsevier Inc. All Rights Reserved. 27

 Issues in Health Care Delivery

 Nursing shortage
 Competency
 Quality and safety in health care
 Pay for performance
 Patient satisfaction

Copyright © 2017, Elsevier Inc. All Rights Reserved. 28

Issues in Health Care Delivery (Cont.)

 Magnet Recognition Program

 Nursing-sensitive outcomes
 Nursing informatics and technological
advancements
 Globalization of health care
 Vulnerable populations

Copyright © 2017, Elsevier Inc. All Rights Reserved. 29

 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.

Copyright © 2017, Elsevier Inc. All Rights Reserved. 30

Quality and Performance Improvement

 Quality data
 Quality improvement (QI)
 Performance improvement (PI)

 Quality improvement programs

 Models
 Patient Self-Determination Act (PSDA)
 Six Sigma or Lean
 Rapid-cycle improvement or rapid-improvement event
(RIE)

Copyright © 2017, Elsevier Inc. All Rights Reserved. 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.
Copyright © 2017, Elsevier Inc. All Rights Reserved. 32