Roles II Unit VIThe 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.

Health Care Delivery System

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

Trends in Nursing Care

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◦ 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

Three Levels of Prevention

Federal Level◦ U.S. Department of Health and Human Services

(DHHS)

State Level◦ Department of Health

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

Health Care Settings Public Sector—Nursing Role

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Hospitals Extended care facilities Home health agencies Hospices Outpatient settings

Health Care Settings Private Sector

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Schools Industrial clinics Managed care organizations Community nursing centers Rural primary care hospitals

Health Care Settings Private Sector

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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

◦ MedicareMedicaid

◦ Regulated by Centers for Medicare & Medicaid Services (CMS)

Economics of Health Care

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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

Federal Government Insurance Plans

.

Cost Access Quality

Factors Influencing the Delivery of Health Care

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

Cost

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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

AccessLimiting Factors

.

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

Quality

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.

Challenges Within the Health Care System

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

Case Management

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Facilitate high quality patient care Encourage high patient satisfaction Promote better outcomes

Magnet Hospitals

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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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RN’s prioritize patient needs

Nurses continue to advocate for ethical distribution of resources as health care reform progresses.

Challenges Within the Health Care System

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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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Nursing’s Response to Health Care Challenges

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

Patient Protection and Affordable Care Act (PPAC)– 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.

PPACA-2011

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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

PPACA--2014

Preventative care with no copay

PPACA--2018

.

Leadership and planning

Delivery systems Legislation/

◦ Regulation policy Professional/nursing

culture Recruitment/

retention

Economic value Work environment Public relations/

communication Education Diversity

Ten Focus Areas of Nursing’s Agenda for the Future

Standards of care Advanced practice Public versus private programs Public health Community health School nursing Long-term care

Nursing’s Response to Health Care Challenges