Roles II Unit VI The Health Care Delivery System
Health Care Delivery System • 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.
Trends in Nursing Care • 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 • 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 .
Health Care SettingsPublic Sector • Federal Level • U.S. Department of Health and Human Services (DHHS) • State Level • Department of Health
Health Care SettingsPublic Sector—Nursing Role • Local Level Health Units • Communicable disease control • Health records maintenance • Individual health services • Environmental health and safety • Public health education
Health Care SettingsPrivate Sector • Hospitals • Extended care facilities • Home health agencies • Hospices • Outpatient settings .
Health Care SettingsPrivate Sector • Schools • Industrial clinics • Managed care organizations • Community nursing centers • Rural primary care hospitals .
Economics of Health Care • Private Insurance • Managed Care • Primary care providers • Health Maintenance Organizations (HMOs) • Preferred Provider Organizations (PPOs) • Company Self pay policy • Alegent system .
Economics of Health Care • Federal Government Insurance Plans • Social Security Act 1965 • Medicare Medicaid • Regulated by Centers for Medicare & Medicaid Services (CMS)
Federal Government Insurance Plans • Medicare • Individuals over age 65 • Public funding • Permanently disabled individuals • Individuals with end-stage renal disease .
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
Factors Influencing the Delivery of Health Care • Cost • Access • Quality .
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
AccessLimiting 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 .
Quality • 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) • 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 .
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.
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 • Children, elderly, chronic disease. homeless
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
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.
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 .
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. .
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. .
Case Management • Discharge planning • Assess needs, coordinate referrals, length of stay, evaluate progress, arrange for equipment /supplies • Social services • Assess needs, assist with application for aid, evaluate discharge environment and care giver support • Utilization review • Track length of stay, review resources used, evaluate level of care and placement
Magnet Hospitals • Facilitate high quality patient care • Encourage high patient satisfaction • Promote better outcomes .
RN’s prioritize patient needs • Assign workers • Supervise care givers • Know practice act for state, job descriptions • Are accountable • Evaluate if delegation was successful .
Challenges Within the Health Care System • Nurses continue to advocate for ethical distribution of resources as health care reform progresses.
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. .
Patient Protection and Affordable Care Act (PPAC)– 2010 • 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
PPACA-2011 • 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. .
PPACA--2014 • 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 .
PPACA--2018 • Preventative care with no copay
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 .
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