Chapter

6

Health Care Delivery Systems
Kozier & Erb's Fundamentals of Nursing, 8e Berman, Snyder, Kozier, Erb Copyright 2008 by Pearson Education, Inc.

Question 1
Which of the following is an example of a primary prevention activity?
3. 4. 5. 6. 7. Antibiotic treatment of a suspected urinary tract infection. Occupational therapy to assist a client in adapting his or her home environment following a stroke. Nutrition counseling for young adults with a strong family. History of high cholesterol. Removal of tonsils for a client with recurrent tonsillitis.
Copyright 2008 by Pearson Education, Inc.

Rationales 1
• Antibiotic therapy is secondary prevention. • Rehabilitation efforts following an illness are considered tertiary prevention. • Correct. Actions such as diet modification that help to prevent an illness or detect it in its early stages are primary prevention. • Surgery is secondary prevention.
Copyright 2008 by Pearson Education, Inc.

Question 2
Which of the following statements is true regarding types of health care agencies? 3. 4. 5. 6. Hospitals provide only acute, inpatient services. Public health agencies are funded by governments to investigate and provide health programs. Surgery can only be performed inside a hospital setting. Skilled nursing, extended care, and long-term care facilities provide care for the elderly whose insurance no longer covers hospital stays.
Copyright 2008 by Pearson Education, Inc.

Rationales 2
• • Hospitals may provide a variety of wellness and clinic programs in addition to inpatient services. Correct. City, county, state, or federal government funds pay for health department and agency activities aimed at the global health of the community. Surgery may be performed in outpatient surgery centers and physicians’ offices in addition to within hospitals. Skilled nursing, extended care, and long-term care facilities provide care to persons of all ages who require rehabilitation or subacute care. This is not necessarily related to insurance coverage for hospital stays. Copyright 2008 by Pearson Education, Inc.

• •

Question 3
In most cases, clients must have a primary care provider in order to receive health insurance benefits. If a client is in need of a primary care provider, it is most appropriate for the nurse to recommend which of the following? 3. 4. 5. 6. Family practice physician Physical therapist Case manager/discharge planner Pharmacist
Copyright 2008 by Pearson Education, Inc.

Rationales 3
• Correct. Primary care providers are limited to generalist physicians and advanced practice nurses. In some cases a gynecologist may qualify as a primary care provider and in other cases not. Physical therapists do not have a scope of practice broad enough to serve as primary care providers. Pharmacists are not responsible for providing direct client care. Case managers/discharge planners are not responsible for providing direct client care.
Copyright 2008 by Pearson Education, Inc.

• • •

Question 4
The most significant method for reducing the ongoing increase in the cost of health care in the United States includes controlling which of the following? 3. 4. 5. 6. Number of children according to the family's income. Numbers of uninsured and underinsured persons. Number of physicians and nurses nationwide. Competition among drug and medical equipment manufacturers.
Copyright 2008 by Pearson Education, Inc.

Rationales 4
• The number of children is increasing, but in the United States and Canada this is a nonmodifiable factor. Also, the majority of health care costs are incurred by adults and elders who tend to have multiple and chronic health conditions. Correct. When people have inadequate insurance for health costs, they tend to avoid early and preventive care. This results in eventual use of much more costly resources such as emergency rooms. Methods to provide minimum levels of insurance coverage have been successful in other countries. There is currently a significant shortage of nurses and maldistribution of physicians so reducing their numbers would only worsen the problem. Competition among manufacturers is more likely to cause costs to fall than to rise.

• •

Copyright 2008 by Pearson Education, Inc.

Question 5
A client is seeking to control health care costs for both preventive and illness care. Although no system guarantees exact out-of-pocket expenditures, the most prepaid and predictable client contribution would be seen with: 2. 3. 4. 5. Medicare. An individual fee-for-service insurance. A preferred provider organization (PPO). A health maintenance organization (HMO).

Copyright 2008 by Pearson Education, Inc.

Rationales 5
• • Medicare covers a minimal number of preventive and outpatient services so the cost cannot be anticipated. Individual fee-for-service insurance is perhaps the most costly to the client, with potentially large differences between the amount of coverage the insurance company pays and the provider’s charges. Correct. A health maintenance organization involves a set monthly membership fee and predictable visit or deductible costs. PPOs are less costly than fee-for-service but more expensive than HMOs.
Copyright 2008 by Pearson Education, Inc.

• •

Types of Health Care Services
• Primary prevention
– Health promotion – Illness prevention

• Secondary prevention
– Diagnosis – Early detection – Treatment

Copyright 2008 by Pearson Education, Inc.

Types of Health Care Services
• Tertiary prevention
– Rehabilitation – Health restoration – Palliative care

Copyright 2008 by Pearson Education, Inc.

Health Care Agencies
• Government agencies
– Public health services

• Physicians’ offices
– Primary care – Routine health screening – Diagnosis and treatment

Copyright 2008 by Pearson Education, Inc.

Health Care Agencies

Copyright 2008 by Pearson Education, Inc.

Health Care Agencies
• Government agencies
– Public health services

• Physicians’ offices
– Primary care – Routine health screening – Diagnosis and treatment

Copyright 2008 by Pearson Education, Inc.

Health Care Agencies
• Ambulatory care centers
– Diagnostic treatment facilities – Minor surgery

• Occupational health clinics
– Run by companies for employees – Health promotion activities

Copyright 2008 by Pearson Education, Inc.

Health Care Agencies
• Hospitals
– – – – Acute inpatient services Outpatient and ambulatory care Emergency department Hospice care

• Subacute care
– Variation of inpatient care – Technically complex treatments
Copyright 2008 by Pearson Education, Inc.

Health Care Agencies
• Extended care facilities (formerly called nursing homes)
– – – – Independent living Assisted, skilled, extended care facilities Rehabilitation Custodial care

• Retirement and assisted-living centers
– For clients unable to stay at home, but do not require hospital or nursing home
Copyright 2008 by Pearson Education, Inc.

Health Care Agencies
• Rehabilitation centers
– Restore or recuperate health – Drug and alcohol

• Home health care agencies
– Education to clients and families – Care to acute, chronic, or terminally ill

• Rural care hospitals
– Federal funding – Services for rural residents
Copyright 2008 by Pearson Education, Inc.

Health Care Agencies
• Day-care centers
– Infants or children – Adults that cannot be left at home

• Hospice services
– Care for dying in home or facility – Improve or maintain quality of life until death

Copyright 2008 by Pearson Education, Inc.

Health Care Agencies
• Crisis centers
– Emergency services for life crises – Counseling and support

• Mutual support or self-help groups
– Health problems – Life crises

Copyright 2008 by Pearson Education, Inc.

Health Care Professionals
• Nurses • Alternative (complementary) care providers • Case manager • Dentists • Dietitians • Nutritionists
Copyright 2008 by Pearson Education, Inc.

Health Care Professionals
RN develops nursing PT designs strengthening care plan
and balance exercise plan MD develops medical care plan, prescribes medications and treatments

Dietician creates low-salt diet

73-year old with heart failure, short of breath

OT designs self-care activities that reserve client's energy

Case Resp Therapist manager communicates provides breathing care plan to Pharmacist treatments family and other supplies and providers teaches about medications

Copyright 2008 by Pearson Education, Inc.

Health Care Professionals
• Alternative (complementary care providers) • Dentists • Nurses • Nutritionists • Occupational therapists • Paramedics/EMTs • Pharmacists • • • • • • • Physical therapists Physicians Physician assistants Podiatrists Respiratory therapists Social workers Spiritual support personnel • Unlicensed assistive personnel (UAPs)
Copyright 2008 by Pearson Education, Inc.

Factors that Affect Health Care Delivery
• • • • • • • • • Increasing number of elderly Advances in technology Economics Women’s health issues Uneven distribution of services Access to health insurance Homeless and the poor HIPAA Demographic changes
Copyright 2008 by Pearson Education, Inc.

Number of Nurses per 100,000 Population Map

Copyright 2008 by Pearson Education, Inc.

Medicare
• For adults over 65 • Part A provides hospitalization, home care, hospice • Part B provides partial outpatient and physician services (voluntary) • Part D prescription plan (voluntary) • Does not cover dental, eyeglasses, hearing aids, etc.
Copyright 2008 by Pearson Education, Inc.

Medicaid
• Financial assistance • Each state is distinct

Copyright 2008 by Pearson Education, Inc.

Supplemental Security Income
• Benefits for people with disabilities • For those not eligible for Social Security

Copyright 2008 by Pearson Education, Inc.

State Children’s Health Insurance Program (SCHIP)
• Insurance coverage for poor and working class children • Includes primary care, prescriptions, hospitalization

Copyright 2008 by Pearson Education, Inc.

Prospective Payment System
• Limits amount paid to hospitals that are reimbursed by Medicare

Copyright 2008 by Pearson Education, Inc.

Private Insurance Plans
• Not-for-profit and For-profit • Most often pay 80% of costs

Copyright 2008 by Pearson Education, Inc.

Health Care Group Plans
• Provide blanket medical service in exchange for monthly payment
– – – – – Health Maintenance Organization (HMO) Preferred Provider Organization (PPO) Preferred Provider Arrangements (PPA) Independent Practice Associations (IPA) Physician/Hospital Organizations (PHO)

Copyright 2008 by Pearson Education, Inc.

Post Test
• Use your clickers to complete the following post test.

Copyright 2008 by Pearson Education, Inc.

Question 1
Which of the following is an example of a primary prevention activity?
3. 4. 5. 6. 7. Antibiotic treatment of a suspected urinary tract infection. Occupational therapy to assist a client in adapting his or her home environment following a stroke. Nutrition counseling for young adults with a strong family. History of high cholesterol. Removal of tonsils for a client with recurrent tonsillitis.
Copyright 2008 by Pearson Education, Inc.

Rationales 1
• Antibiotic therapy is secondary prevention. • Rehabilitation efforts following an illness are considered tertiary prevention. • Correct. Actions such as diet modification that help to prevent an illness or detect it in its early stages are primary prevention. • Surgery is secondary prevention.
Copyright 2008 by Pearson Education, Inc.

Question 2
Which of the following statements is true regarding types of health care agencies? 3. 4. 5. 6. Hospitals provide only acute, inpatient services. Public health agencies are funded by governments to investigate and provide health programs. Surgery can only be performed inside a hospital setting. Skilled nursing, extended care, and long-term care facilities provide care for the elderly whose insurance no longer covers hospital stays.
Copyright 2008 by Pearson Education, Inc.

Rationales 2
• • Hospitals may provide a variety of wellness and clinic programs in addition to inpatient services. Correct. City, county, state, or federal government funds pay for health department and agency activities aimed at the global health of the community. Surgery may be performed in outpatient surgery centers and physicians’ offices in addition to within hospitals. Skilled nursing, extended care, and long-term care facilities provide care to persons of all ages who require rehabilitation or subacute care. This is not necessarily related to insurance coverage for hospital stays. Copyright 2008 by Pearson Education, Inc.

• •

Question 3
In most cases, clients must have a primary care provider in order to receive health insurance benefits. If a client is in need of a primary care provider, it is most appropriate for the nurse to recommend which of the following? 3. 4. 5. 6. Family practice physician Physical therapist Case manager/discharge planner Pharmacist
Copyright 2008 by Pearson Education, Inc.

Rationales 3
• Correct. Primary care providers are limited to generalist physicians and advanced practice nurses. In some cases a gynecologist may qualify as a primary care provider and in other cases not. Physical therapists do not have a scope of practice broad enough to serve as primary care providers. Pharmacists are not responsible for providing direct client care. Case managers/discharge planners are not responsible for providing direct client care.
Copyright 2008 by Pearson Education, Inc.

• • •

Question 4
The most significant method for reducing the ongoing increase in the cost of health care in the United States includes controlling which of the following? 3. 4. 5. 6. Number of children according to the family's income. Numbers of uninsured and underinsured persons. Number of physicians and nurses nationwide. Competition among drug and medical equipment manufacturers.
Copyright 2008 by Pearson Education, Inc.

Rationales 4
• The number of children is increasing, but in the United States and Canada this is a nonmodifiable factor. Also, the majority of health care costs are incurred by adults and elders who tend to have multiple and chronic health conditions. Correct. When people have inadequate insurance for health costs, they tend to avoid early and preventive care. This results in eventual use of much more costly resources such as emergency rooms. Methods to provide minimum levels of insurance coverage have been successful in other countries. There is currently a significant shortage of nurses and maldistribution of physicians so reducing their numbers would only worsen the problem. Competition among manufacturers is more likely to cause costs to fall than to rise.

• •

Copyright 2008 by Pearson Education, Inc.

Question 5
A client is seeking to control health care costs for both preventive and illness care. Although no system guarantees exact out-of-pocket expenditures, the most prepaid and predictable client contribution would be seen with: 2. 3. 4. 5. Medicare. An individual fee-for-service insurance. A preferred provider organization (PPO). A health maintenance organization (HMO).

Copyright 2008 by Pearson Education, Inc.

Resources
• Audio Glossary • Case Management Resource Guide Searchable database of over 120,000 specialty health care services, facilities, businesses, and organizations • Critical Pathways in Home Care This site defines critical pathways and their use in home care. • Medicare: Alternatives to Nursing Home Care The Official U.S. Government site for people with Medicare offers information on alternatives to nursing home care. • Medicare: Nursing Homes Overview The Official U.S. Government site for people with Medicare gives an overview of nursing homes. • Centers for Medicare & Medicaid Services Information and press releases on topics pertaining to Medicaid and Medicare
Copyright 2008 by Pearson Education, Inc.

Resources
• Healthy People 2010 This site contains the Healthy People 2010 documents • The National Academies News U.S. Health Care Delivery System Needs Major Overhaul To Improve Quality and Safety • Harvard Medical School Department of Health Care Policy The Department of Health Care Policy is to serve the nation as a leading source for scientific knowledge about our health care system. • 21st Century Advances The Office on Women's Health in the U.S. Department of Health and Human Services • Council on Health Care Economics and Policy This site provides information on health care policy research and information from key experts in health care economics.
Copyright 2008 by Pearson Education, Inc.

Sign up to vote on this title
UsefulNot useful