chapter 3 the healthcare delivery system

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 3

The Healthcare Delivery System


Healthcare 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*• *Interdisciplinary health education for collaborative

practice• Changing demographics*• Globalization 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 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.

• Clients may be transitioned or transferred from one level of care to another*


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


*Healthcare Settings and Services• ICU’s

– Specialize in medical, surgical, respiratory, coronary, burn, neonatal and pediatric

• Subacute care facility– May moved to this type of care as acuity decreases

• Outpatient– Same day surgeries


• Specialized Hospitals– These facilities admit only one type of client for

specific conditions. – University hospitals are teaching facilities as well*

• 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 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

• **Extended care facilities– SNF– ICF

Healthcare Settings and Services (cont’d)


Community 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 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 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 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.– Establishes minimal standards of service to the client

and the community*• It requires objective and systematic monitoring and

evaluation of the quality and appropriateness of client care.


Relation 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 Facilities• Quality assurance focus on delivery of care. The standards

of quality include:– *Standards of nursing practice

• Procedures used in care delivery, hospital policy book, textbooks and other references

– Standards of client/patient care– Standards of performance

• *how well the nurse performs as compared to job description

• 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 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.


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 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 Payment• Individual Private Insurance • Group Insurance • Fee for Service Plans• Health Maintenance Organizations

– Fee or premium paid in advance to the HMO is called the capitation fee*

• Preferred Provider Organizations (PPOs)• Point of Service Plans (POS)


Methods of Payment (cont’d)• *Medicare

– federal health insurance program that is available to most people 65 or older

– Young people with disabilities younger than 65– People with end-stage renal disease

• Medicaid– *joint federal and state effort

• Prospective Payment • Diagnosis-Related Groups (DRGs)


Complementary Healthcare• Chiropractic• Physical and Occupational Therapy

– Forms of rehab after disease or injury*• Holistic Healthcare• Herbalists and Vibrational Remedies • *Acupuncture and Acupressure • *Relaxation and Imagery (calling up mental pictures or

events after the client relaxes)• Meditation • Therapeutic Touch


Consumer 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. – Public spends an estimated $25 billion per year on

these “sure cures”*• 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.

chapter 3 the healthcare delivery system

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