Health Care Delivery Systems

Health Care Delivery Systems

• Health care delivery systems involve interactions between health care providers and clients.
• Interactions are subject to financial and regulatory constraints.
• Health care systems encompass participating clients, care settings, regulatory bodies, and financial support mechanisms.
• Nurses provide care within health care systems and strive to maintain caring values while managing costs amid business-driven approaches.

Components of Health Care Systems

• Participants include consumers (clients) and providers.
• Licensed providers include registered nurses, licensed practical nurses (LPNs), advanced practice nurses (APNs), and medical doctors.
• Also included are: pharmacists, dentists, dietitians, and physical, respiratory, and occupational therapists.
• Unlicensed providers are assistive personnel.
• Settings for health care delivery: hospitals, homes, skilled-nursing, assisted-living, and extended-care facilities
• Also included are: community/health departments, adult day care centers, and schools
• More settings include: hospices, providers' offices, ambulatory care clinics, and occupational health clinics
• Additional settings: stand-alone surgical centers, urgent care centers, complementary therapy centers, and urgent and emergent care centers
• Other settings: public health agencies, crisis centers, diagnostic centers, and specialized services centers (dialysis, oncology, rehabilitation, burn)

Regulatory Agencies

• U.S. Department of Health and Human Services
• U.S. Food and Drug Administration (FDA)
• State and local public health agencies
• State licensing boards ensure health care provider compliance with regulations.
• The Joint Commission sets quality standards for health care facilities accreditation.
• Professional Standards Review Organizations monitor provided health care services.
• Utilization review committees oversee appropriate diagnosis and treatment of hospitalized clients.

Health Care Financing Mechanisms

• Medicare serves clients aged 65+ and those with permanent disabilities and is a public federally funded program.
• Medicare Part A covers hospital stays, home health, and hospice, for those 65+ or with permanent disabilities.
• Medicare Part B covers outpatient and provider services for those 65+ or with permanent disabilities; it is voluntary and requires a monthly premium.
• Medicare Part C is an advantage or supplement plan, potentially covering parts A, B, and sometimes D.
• Medicare Part D covers medications for eligible individuals, requiring a monthly premium.
• Medicaid serves clients with low incomes, and is jointly funded by the federal government and individual states.
• Individual states determine Medicaid eligibility.
• The Patient Protection and Affordable Care Act of 2010 aims to increase health care access, mandate insurance coverage, decrease health care costs, and provide affordable insurance options.
• The State Children’s Health Insurance Program provides coverage for uninsured children up to age 19 at a lower cost to parents.

Private Health Plans

• Traditional insurance reimburses on a fee-for-service basis.
• Managed Care Organizations (MCOs) feature primary care providers overseeing comprehensive care with a focus on prevention.
• Preferred Provider Organizations (PPOs) allow clients to choose contracted providers/hospitals, but using non-contracted providers increases out-of-pocket costs.
• Exclusive Provider Organizations (EPOs) allow clients to select providers/hospitals within a contracted organization, without out-of-network coverage.
• Long-term care insurance supplements long-term care expenses, but Medicare does not cover it.

Social Determinants of Health

• Social determinants of health (SDOH) are environmental factors affecting health, outcomes, and quality of life. SDOH are divided into six categories:
• Neighborhood and Built Environment includes geographical layout, crime rate, and air and water quality.
• Neighborhood and Built Environment covers living arrangements and accessible outdoor spaces.
• Social and Community Context refers to relationships and interactions with others and transportation systems.
• Economic Stability involves the ability to seek health care, employment status, and child-care opportunities.
• Food and Nutrition includes the availability of food/nutrients, access to healthy options, and sources of food.
• Health and Health Care includes availability of services, health insurance, and availability of screening services.
• Education involves the level of education, quality of the educational system, and presence of social discrimination.
• Family beliefs, cultural values, genetics, and environment influence individual health.

Role of the Nurse

• Advocate for improved access to health care services.
• Perform individual risk assessments.
• Conduct cultural assessments to determine how religion, beliefs, language, family roles, support, and dietary practices affect healthcare access.
• Nurses should maintain cultural competence, sensitivity, and appropriateness.
• Conduct environmental assessments to determine safety, including neighborhood safety, and the presence of hazards.
• Identify systems that support access to healthcare.
• Identify and discuss ethical issues impacting healthcare access.
• Participate in policy development.

Access to Health Care

• The goal is comprehensive, accessible, and affordable health care that accommodates income variations.
• Those without insurance may experience a lack of access due to cost.
• The Patient Protection and Affordable Care Act has increased access to affordable coverage.
• Insured clients tend to have better, more predictable health outcomes.

Barriers to Health Care

• Include inadequate insurance, inability to pay for services, and language/cultural differences
• Also include lack of providers, geographic isolation, transportation issues, distance, and wait times.

Interventions

• Nurses promote health and prevent injury by addressing social determinants.
• Primary prevention involves advocating for healthcare and educating about environmental hazards, nutrition, exercise, immunization, and hygiene.
• Secondary prevention involves environmental/cultural assessments and implementing screening techniques.
• Tertiary prevention includes assisting with transportation and providing access to insurance programs.

Levels of Health Care

• Preventive care aims to reduce risk factors through education and programs like immunization and stress management.
• Primary care emphasizes promotion; it includes prenatal care, family planning, and disease control via office visits and screenings.
• Secondary care includes diagnosis and treatment of acute conditions in hospitals, diagnostic centers, and urgent care facilities.
• Tertiary care provides specialized, technical care in intensive care, oncology, and burn centers.
• Restorative care is intermediate follow-up for restoring health in home health, rehabilitation, and skilled nursing facilities.
• Continuing care addresses long-term needs in end-of-life care, palliative care, hospice, adult day care, and respite care.

Relationship Between Health Care Systems and Levels of Care

• The level of care depends on the client's needs, and licensed/unlicensed personnel work at every level.
• Secondary and tertiary care settings are usually hospitals or specific facilities, while other settings vary.
• Regulatory agencies ensure the quality and quantity of health care, protecting consumers.
• Health care finance impacts care quality and type via cost containment and reimbursement parameters.

Safety and Quality

• The Quality and Safety Education for Nurses (QSEN) initiative prepares nurses to provide safe, high-quality care.
• QSEN competencies include safety (minimizing risk), patient-centered care (compassionate, culturally sensitive care), and evidence-based practice basing care on research.
• QSEN competencies include informatics (using technology to support clinical decisions), quality improvement, and teamwork/collaboration (interprofessional partnership).

The Future of Health Care

• It is focused on ensuring the health and welfare of the population.