The Health Care Delivery System

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The Health Care Delivery System
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Mechanism for providing services that meet
the health-related needs of individuals.
major focus on quality and patient safety
Nursing is a major component of the U.S.
health care delivery system.
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Quality/safety
◦ Evidenced based practice (EBP)
 QSEN Standards
 NLN Standards
 Core Measures
◦ Safety standards (JCAHO)
 Leapfrog group
◦ Emergency preparedness
 Triage is the key
◦ Scientific and technical advancements
 Robots, machines to do nursing work
◦ Hospitalists programs
 Work with the nursing staff, part of hospital—not
independent
◦ Information technology
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Improves nursing quality
Reduces costs
Enhances work flow
Allows for use of best practices
◦ Demand for quality care
 Public well informed….or misinformed
 Individual appraises nursing actions
 Unit outcomes
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Federal Level
◦ U.S. Department of Health and Human Services
(DHHS)
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State Level
◦ Department of Health
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Local Level Health Units
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Communicable disease control
Health records maintenance
Individual health services
Environmental health and safety
Public health education
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Hospitals
Extended care facilities
Home health agencies
Hospices
Outpatient settings
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Schools
Industrial clinics
Managed care organizations
Community nursing centers
Rural primary care hospitals
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Private Insurance
Managed Care
◦ Primary care providers
◦ Health Maintenance Organizations (HMOs)
◦ Preferred Provider Organizations (PPOs)
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Company Self pay policy
◦ Alegent system
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Federal Government Insurance Plans
◦ Social Security Act 1965
◦ Medicare
Medicaid
◦ Regulated by Centers for Medicare & Medicaid
Services (CMS)
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Medicare
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Individuals over age 65
Public funding
Permanently disabled individuals
Individuals with end-stage renal disease
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Medicaid
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Medically indigent
Determined by federal and state governments
Inpatient and outpatient hospital services
Physician services
Laboratory services
Rural health clinic services
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Cost
Access
Quality
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Four major factors increase the cost of health
care
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An over supply of specialized providers
A surplus of hospital beds
The passive role assumed by most consumers
Inequitable financing of services
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Prohibitive costs for employer to provide
Inability to obtain individual insurance
Cultural barriers
Persons with preexisting conditions
Shortages of health care providers
Limited access to ancillary services
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Estimated that 30% to 40% of
diagnostic/medical procedures performed in
U.S. are unnecessary
Inappropriate use of resources
U.S. per capita healthcare spending= $8,000
◦ (2008 stats)
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Institute of Medicine (IOM) report
◦ Change recommendations for nursing/healthcare
access
 BSN at bedside
 Ability to share patient info across all points of entry
 EPIC
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Positive Perception of Nurses
◦ Nurses are persistently seen as having the highest
standards of honesty and ethics.
◦ The public believes that if nurses were allowed to
use their skills, they would significantly enhance
quality and reduce costs.
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Nursing shortage
Loss of control over health care decisions
Decreased use of hospitals
Changing practice settings
Ethical issues
Vulnerable populations
◦ Children, elderly, chronic disease. homeless
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Nursing Shortage: By 2020 the workforce is
forecast to be 20% below requirements.
◦ Fewer people entering the profession
◦ Aging of the nursing population
◦ Other career options offering greater remuneration
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Loss of Control
◦ Consumers express a loss of personal control
within the health care system.
◦ Some feel terrorized by the system.
◦ Many American workers state that their greatest
concern is the possible loss of health care coverage.
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Decreased use of hospitals
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Shorter lengths of stay
Technologic advances
Greater availability of outpatient facilities
More services available in outpatient settings
Expectations/demands of third-party payers
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Changing Practice Settings
◦ Most nurses currently practice in hospitals and will
continue to do so in the future.
◦ There is an ever-increasing need for expanded
services and settings.
◦ Larger numbers of nurses will be needed for
primary care, public health, extended care facilities,
and the home setting.
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Ethical Issues
◦ At present, citizens’ needs are greater than
available resources.
◦ The United States is struggling with major ethical
conflicts over allocation of scarce resources versus
compassionate quality care.
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Discharge planning
◦ Assess needs, coordinate referrals, length of stay,
evaluate progress, arrange for equipment /supplies
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Social services
◦ Assess needs, assist with application for aid,
evaluate discharge environment and care giver
support
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Utilization review
◦ Track length of stay, review resources used,
evaluate level of care and placement
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Facilitate high quality patient care
Encourage high patient satisfaction
Promote better outcomes
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Assign workers
Supervise care givers
Know practice act for state, job descriptions
Are accountable
Evaluate if delegation was successful
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Nurses continue to advocate for ethical
distribution of resources as health care
reform progresses.
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Nursing’s Agenda for the Future is a plan that
focuses on strategies to improve professional
conditions for nurses and quality of health
care by 2010.
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Major overhaul of healthcare system
◦ ‘donut hole’ protection for seniors- rebate to
supplement drug coverage max
◦ Eliminating pre existing restrictions
◦ Increasing age to 26 to be covered on parent’s plan
◦ Eliminating insurance dropping
◦ Increased tax on tanning (tax goes to cancer
research)
◦ healthcare.gov website transparency
◦ New food labeling
Source: Nursing Now! 2010
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Tax credits for small business providing
insurance to <50 employees
Reduced out of pocket expenses for
employees
2 year temporary credit for research into new
therapies.
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Eliminating pre existing for adults
Eliminating increased ins. Payment based on
gender or health status
No lifetime caps
Increased payment for medicare to rural
hospitals
Options of coverage thru state run exchanges
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Preventative care with no copay
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Leadership and
planning
Delivery systems
Legislation/
◦ Regulation policy
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Professional/nursing
culture
Recruitment/
retention
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Economic value
Work environment
Public relations/
communication
Education
Diversity
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Standards of care
Advanced practice
Public versus private programs
Public health
Community health
School nursing
Long-term care
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