Chapter 2
The Health Care
Delivery System
Health Care Delivery System?
 Mechanism for providing services that
meet the health-related needs of
individuals.
 Nursing is a major component of the U.S.
health care delivery system.
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-2
Types of Health Care Services
 Primary: Health promotion and illness
prevention
 Secondary: Diagnosis and treatment
 Tertiary: Rehabilitation
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-3
Three Levels of Prevention
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-4
Health Care Settings
Public Sector
 Federal Level
• U.S. Department of Health and Human
Services (DHHS)
 State Level
• Department of Health
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-5
Health Care Settings
Public Sector
 Local Level Health Units
•
•
•
•
•
Communicable disease control
Health records maintenance
Individual health services
Environmental health and safety
Public health education
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-6
Public Health Sector of Health
Care Delivery
Federal Level
U.S. Department of Health and Human Services (DHHS)
State Level
Department of Health
Local Level
Health Units
Communicable
Disease Control
Health Records
Maintenance
(Vital Statistics)
Individual
Health Services
(e.g. MaternalChild Health
Programs)
Environmental
Health and
Safety
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Public Health
Education
2-7
Health Care Settings
Private Sector





Hospitals
Extended care facilities
Home health agencies
Hospices
Outpatient settings
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-8
Health Care Settings
Private Sector





Schools
Industrial clinics
Managed care organizations
Community nursing centers
Rural primary care hospitals
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-9
Health Care Team







Nurse (RN)
Physician (MD)
Physician Assistant (PA)
Pharmacist (RPh)
Dentist (DDS)
Dietitian (RD)
Social Worker (SW)
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-10
Health Care Team






Respiratory Therapist (RT)
Physical therapist (PT)
Occupational Therapist (OT)
Chaplain
Unlicensed Assistive Personnel (UAP)
Dental Hygienist
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-11
Advanced Practice Registered
Nurse
 Diagnoses and manages common health
problems.
 Performs medical procedures (e.g.,
suturing, casting).
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-12
Nursing Roles







Caregiver
Teacher
Advocate
Manager
Expert
Case Manager
Team Member
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-13
Roles of the Nurse







Caregiver
Teacher
Advocate
Manager
Expert
Case Manager
Team Member
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-14
Economics of Health Care
 Private Insurance
 Managed Care
•
•
•
•
Primary care providers
Health Maintenance Organizations (HMOs)
Preferred Provider Organizations (PPOs)
Exclusive Provider Organizations (EPOs)
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-15
Economics of Health Care
 Federal Government Insurance Plans
• Social Security Act 1965
• Medicare and Medicaid
• Regulated by Centers for Medicare &
Medicaid Services (CMS)
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-16
Federal Government Insurance
Plans
 Medicare
•
•
•
•
Individuals over age 65
Public funding
Permanently disabled individuals
Individuals with end-stage renal disease
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-17
Federal Government Insurance
Plans
 Medicaid
• Medically indigent
• Determined by federal and state
governments
• Inpatient and outpatient hospital services
• Physician services
• Laboratory services
• Rural health clinic services
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-18
Economics of Health Care
 Canadian Health Insurance
•
•
•
•
National health insurance
Single-payer model
Short and long-term care
Financed with tax dollars
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-19
Factors Influencing the Delivery
of Health Care
 Cost
 Access
 Quality
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-20
Cost
 Four major factors increase the cost of
health care
• An over supply of specialized providers
• A surplus of hospital beds
• The passive role assumed by most
consumers
• Inequitable financing of services
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-21
Access Limiting Factors






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
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-22
Quality
 Estimated that 30% to 40% of
diagnostic/medical procedures performed
in U.S. are unnecessary
 Inappropriate use of resources
 A 2002 study revealed that 73% of
nurses surveyed stated that the quality of
care at their hospital had declined due to
cost-containment measures.
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-23
Challenges Within the
Health Care System
 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.
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-24
Challenges Within the
Health Care System






Nursing shortage
Loss of control over health care decisions
Decreased use of hospitals
Changing practice settings
Ethical issues
Vulnerable populations
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-25
Challenges Within the
Health Care System
 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
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-26
Challenges Within the
Health Care System
 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.
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-27
Challenges Within the
Health Care System
 Decreased use of hospitals
•
•
•
•
Shorter lengths of stay
Technologic advances
Greater availability of outpatient facilities
More services available in outpatient
settings
• Expectations/demands of third-party payers
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-28
Challenges Within the
Health Care System
 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.
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-29
Home Health Nursing
 The percentage of home health nurses is increasing in
numbers, as health care reform places more nurses
(as this home health nurse) outside the acute care
setting.
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-30
Challenges Within the
Health Care System
 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.
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-31
Challenges Within the
Health Care System
 Nurses continue to advocate for ethical
distribution of resources as health care
reform progresses.
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-32
Challenges Within the
Health Care System
 Vulnerable Populations
•
•
•
•
•
Children
The elderly
People with AIDS
The homeless
Others living in poverty
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-33
Vulnerable Populations
 Children
• Children are more likely to be insured than
adults.
• One in five children lives in a family with an
income below the poverty level.
• The State Children’s Health Insurance
Program was passed in 1997 to expand
health insurance coverage to uninsured low
income children.
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-34
Vulnerable Populations
 The Elderly
• A large number of elderly people live in rural
areas.
• Many elderly have no health insurance.
• Many hospitals in rural areas have been
closed due to economic pressures.
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-35
Vulnerable Populations
 People with AIDS
• Over 300,000 Americans have been
diagnosed with AIDS.
• Approximately 800,000 Americans are
infected with HIV.
• The most rapid spread of the disease is
occurring among women, children, and IV
drug users and their sexual partners.
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-36
Nursing’s Response to Health
Care Challenges
 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.
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-37
Ten Focus Areas of Nursing’s
Agenda for the Future
 Leadership and
planning
 Delivery systems
 Legislation/regulation
policy
 Professional/nursing
culture
 Recruitment/
retention
 Economic value
 Work environment
 Public relations/
communication
 Education
 Diversity
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-38
Nursing’s Response to Health
Care Challenges







Standards of care
Advanced practice
Public versus private programs
Public health
Community health
School nursing
Long-term care
Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
2-39