Chapter 3 The Healthcare Delivery System

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 3

The Healthcare Delivery System

Chapter 3

The Healthcare Delivery System


Healthcare Trends and Challenges in the 21st CenturyHealthcare Trends and Challenges in the 21st Century• There is an emphasis on wellness and individuals

assuming more responsibility for their own health.

• Technology continues to influence healthcare.

• The rising costs of healthcare are to be met by preventive care.

• Health education is an important aspect of healthcare.

• Health maintenance organizations (HMOs) provide managed care; they emphasize disease prevention and health promotion.


The Impact of the Changes on Nurses, Healthcare Practitioners, and ClientsThe Impact of the Changes on Nurses, Healthcare Practitioners, and Clients

• Healthcare may involve discussion among the healthcare practitioner, an insurance provider, and the client.

• With the increasing challenges, it is not uncommon for unlicensed assistive personnel (UAPs) to be hired to administer nursing care.

• As a result of financial constraints and the influence of managed care plans, clients may even be forced to have treatment outside a hospital.


The Impact of the Changes on Nurses, Healthcare Practitioners, and ClientsThe Impact of the Changes on Nurses, Healthcare Practitioners, and Clients

• As a result of specific changes in the delivery of healthcare services, extended care facilities (ECFs) and home healthcare services have restructured to meet the intermediate acuity needs of clients.

• For example, a client may be discharged from an acute care hospital to be admitted into an extended care facility to received physical therapy and rehabilitation before being discharged to home.


Acute Care and Extended Care Facilities Acute Care and Extended Care Facilities

Acute Care Facilities Extended Care Facilities

Clients with serious conditions or high level of acuity are admitted for a short period.

Clients discharged from acute care facilities may be admitted for a longer period.

Include:

•Acute care hospitals•Intensive care units•Subacute care facilities

Include:

•Skilled nursing facilities•Intermediate care facilities •Inpatient rehabilitation centers


Outpatient Care CentersOutpatient Care Centers

• Most general hospital provide “same day” surgery, also known as outpatient or ambulatory care centers.


• Specialized Hospitals

– These facilities admit only one type of client for specific conditions.

• Home Healthcare

– Service provided by an acute care facility or an agency that specializes in home healthcare.

• Hospice

– Specializes in the care of the terminally ill

Healthcare Settings and ServicesHealthcare Settings and Services


• Respite Care

– Part-time supervision of clients who have chronic conditions

• Telehealth

– Ability to access a nurse or physician via telephone or computer audio/video link

Healthcare Settings and Services (cont’d)Healthcare Settings and Services (cont’d)


Question Question

Is the following statement true or false?

Extended care facilities include intensive care units for the critically ill.


Answer Answer

False

Clients who are admitted to the intensive care unit meet the minimal level or need for healthcare services known as acuity and are thus admitted to acute care facilities, not extended care facilities.


Community Health ServicesCommunity Health Services

• Public health service

– Immunizations, well-baby checks, and treatment for specific diseases

• Community health clinics

– Low-cost healthcare services to the public

• Independent living facilities

– Stable, home-like environment for mentally challenged individuals


School NurseSchool Nurse

• Cares for ill children

• Provides intensive nursing care for the physically challenged

• Promotes preventive care by regular assessments, teaching, and screening for common disorders

• Supervises administration of immunizations and medications

• Provides teaching and health counseling


Industrial NurseIndustrial Nurse

• Promotes health

• Teaches prevention of accidents

• Serves as a liaison between the industry and the Occupational Safety and Health Administration (OSHA)


Functions of The Joint CommissionFunctions of The Joint Commission• The Joint Commission accredits a hospital or other

healthcare facility.

• It has established rigid standards for an ongoing quality assurance program in acute care and extended care facilities.

• It requires objective and systematic monitoring and evaluation of the quality and appropriateness of client care.


Relation of The Joint Commission’s Functions to NursingRelation of The Joint Commission’s Functions to Nursing

• The Joint Commission stresses the importance of quality assurance. As a result, facilities and agencies have contiguous quality improvement (CQI) committees that monitor the quality of ongoing care.

• The process of care relates to how care is given. The outcome, which is equally important, relates to the result, which is also known as outcome-based care. Thus, nurse accountability, which involves the delivery and accurate documentation of quality care, is vital.


Quality Assurance in Healthcare FacilitiesQuality Assurance in Healthcare Facilities

• Quality assurance focus on delivery of care. The standards of quality include:

– Standards of nursing practice

– Standards of client/patient care

– Standards of performance

• The nursing audit committee or CQI committee evaluates care given to clients.

• Peer review allows nurses to constructively critique each other.


Roles of the Client Representative and Advocate or OmbudspersonRoles of the Client Representative and Advocate or Ombudsperson• To act as a consumer advocate and assist the client and

family by resolving concerns or problems

• To focus on client care, needs, and concerns, and listen and answer questions

• To help clients and their families find needed services like housing, child care, etc

• During hospitalization, clients have the right to contact their representatives if they have a concern. Each individual receives a copy of the Patient’s Bill of Rights. The nursing case manager has overall responsibility for the client’s care, and the advocate assists as needed.


Question Question

Is the following statement true or false?

A client representative can also be called a consumer advocate.


Answer Answer

True

Client representatives act as consumer advocates and assist the client and family by resolving concerns or problems.


Hospital Organization and Ownership Hospital Organization and Ownership

• Numerous trained individuals work together in organized units

• Government ownership

• Private ownership

– Proprietary, investor-owned, or for-profit

– Not-for-profit


Financing HealthcareFinancing Healthcare

• The Health Planning and Resources Development Act of 1975 established legislation to govern the amount and types of facilities, services, and workers needed in each designated geographic area in the United States.

• Resources for the 21st century must include at least 24 healthcare priorities.


Methods of PaymentMethods of Payment

• Individual Private Insurance: private health insurance.

• Group Insurance: companies, institutions, fraternal organizations.

• Fee for Service Plans: medical bills, hospitalization, surgery, laboratory.

• Health Maintenance Organizations (HMOs): fixed monthly charge called premium.

• Preferred Provider Organizations (PPOs): deliver healthcare within a “managed” system.


Methods of Payment (cont’d)Methods of Payment (cont’d)• Point of Service Plans (POS): similar to HMO and PPO they are

all types of managed care.

• Medicare: federal health insurance (people 65 years of age, disabilities younger 65) Part A- covered hospital, nursing facilities, hospice ect. Part B- physician services, outpatient hospitals and medications.

• Medicaid: is the United States health program for certain people and families with low incomes and resources. It is a means-tested program that is jointly funded by the state and federal governments, and is managed by the states.

• Prospective Payment: is a reimbursement system in which determinate amount of is allocated for treating individuals with specific diagnoses. If this reimbursement occurred years past ,then is called: retrospective payment.


Cont’dCont’d

• Diagnosis-Related Groups (DRGs): Prospective Payment is based in DRGs, for hospital and home care, the original objective of diagnosis related groups (DRG) was to develop a classification system that identified the "products" that the patient received. Since the introduction of DRGs in the early 1980s, the healthcare industry has evolved and developed an increased demand for a patient classification system that can serve its original objective at a higher level of sophistication and precision. To meet those evolving needs, the objective of the DRG system had to expand in scope. Today, there are several different DRG systems that have been developed in the US. Some hospitals and home care had to adjusted their expensives in order to survive.


Question Question

Which of the following is not a feature of HMOs?

a. Each plan has a predetermined co-pay.

b. Members can use any physician they choose, and the HMO will pay for this service.

c. A premium must be paid in advance to the HMO.

d. Members prepay for healthcare services generally through payroll deductions, etc.

e. Most HMOs include group practice, prepayment, prevention, and treatment.


Answer Answer

b. Members can use any physician they choose, and the HMO will pay for this service.

Members must use a physician within the HMO network. HMO members can elect to go to any physician or seek any medical service that is not part of the HMO network. However, the HMO will generally not pay for this service unless it is preapproved by the administrators of the plan.


Complementary HealthcareComplementary Healthcare• Chiropractic, Physical, and Occupational Therapy

• Holistic Healthcare

• Herbalists and Vibrational Remedies

• Acupuncture and Acupressure

• Relaxation and Imagery

• Meditation

• Therapeutic Touch


Consumer FraudConsumer Fraud

• As a result of misleading the public with “sure cures,” ill people run the risk of delaying vital treatment for diseases such as cancer and obesity until it is too late.

• The general public often cannot tell the difference between true and false claims. As a nurse, you may encourage clients to find out all the facts before starting any untested healthcare measure.


End of Presentation

Chapter 3 The Healthcare Delivery System

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