RN Engage 2.0 - Health Care Delivery

Structure of the Health Care Delivery System

• The U.S. health care system is continuously changing, with regulatory agencies setting standards and guidelines to ensure quality and safe care.
• Compliance with these regulations, guidelines and monitoring ensures facilities provide quality services to clients.

Health Care Reform

• Many individuals in the U.S. lack insurance, struggle to afford medications, or have limited health care access, leading to potential negative health outcomes.
• Efforts are underway to make health care more affordable and accessible through reforms such as the Affordable Care Act (ACA).
• The Patient Protection and Affordable Care Act (ACA) was signed into law in 2010 with the goals of improving health care quality, lowering costs, and increasing access to care.
• ACA expanded Medicaid eligibility to adults with incomes below 138% of the federal poverty level and banned lifetime caps on insurance benefits.
• A primary focus of the ACA is disease prevention, encouraging clients to seek preventive care before illness to maintain health.
• Insured clients receive free screenings for preventable diseases.
• Affordable health care continues to evolve, providing coverage to those with pre-existing conditions, but many still lack coverage or cannot afford premiums.
• The ACA marketplace is a platform for individuals, families, and businesses to obtain subsidized insurance.
• Health insurance premiums have drastically increased in recent years and high deductibles prevent access to care, even with ACA coverage.
• The American Rescue Plan (ARP) Act of 2021 strengthened the ACA, by lowering health care costs and expanding Medicaid coverage, resulting in more affordable and accessible health care.
• Nurses play a crucial role in educating clients about the importance of preventative health care.

State Regulation

• Each state has its own health care regulations that organizations must follow and nurses are responsible for following these policies and procedures.
• Approximately one-third of a state's budget is allocated to health care costs.
• States can refine definitions of chronic illness to control reimbursement with financial implications for both clients and the state.
• Each state interprets federal definitions and regulates Medicaid funding, including its own State Child Health Insurance Program (SCHIP).
• States can regulate pharmaceutical prices to control costs, while the Inflation Reduction Act of 2022, aims to lower prescription drug costs for Medicare recipients.
• States regulate health care practitioners' operations, determining eligibility, issuing licenses, governing policies, and handling disciplinary cases through bodies like the State Board of Nursing (BON).
• The National Council of State Boards of Nursing (NCSBN) offers guidance to state BONs.

Accreditation

• Accreditation by external organizations signifies a facility's commitment to quality and safety through adherence to operational standards and procedures.

The Joint Commission

• The Joint Commission (TJC) is a nonprofit organization that accredits health care organizations in multiple settings.
• TJC surveyors assess facilities for quality and safety through documentation review, observations, and interviews, offering guidance for improvement.
• Full TJC accreditation is valid for three years and is recognized by many state regulatory bodies, potentially waiving additional state requirements.
• Accredited organizations must remain current with state requirements.
• Facilities seeking accreditation must meet standards in the TJC manual, demonstrating compliance through discussion, chart review, or written policies. Deficits can negatively impact the facilitys accreditation.
• TJC publishes National Patient Safety Goals (NPSGs) annually based on current safety issues, with specific goals for different care settings.
• TJC develops new requirements or modifies current NPSG requirements based on the trends in patient safety.
• Facilities reporting major safety issues will lead to TJC publishing a sentinel event alert.
• A sentinel event results in severe harm or death to a client.
• Examples of sentinel events include administering blood products with the incorrect blood type, infant death, and a surgical procedure done on the incorrect area of the body.
• Organizations investigate sentinel events to identify the root cause to prevent reoccurrence.
• Joint commission partners with organizations to develop safe practices to avoid problems in the future.
• Reviewing sentinel events allows preventive measures to be put in place before another event occurs.

National Committee for Quality Assurance

• The National Committee for Quality Assurance (NCQA) is an independent, nonprofit organization that accredits various healthcare entities.
• NCQA improves health care through evidence-based standards.

Nursing Excellence Programs

• The American Nurses Credentialing Center (ANCC) developed the Magnet Recognition Program and the Pathway to Excellence to recognize quality nursing practice.

American Nurses Credentialing Center (ANCC)

• Health care organizations can apply for and be awarded these programs in addition to obtaining TJC accreditation.

Magnet Recognition Program®

• The Magnet Recognition Program recognizes health care organizations for excellence in nursing care.
• The goals of the Magnet Recognition Program are promoting quality in a setting that supports professional practice, identifying excellence in the delivery of nursing services to clients, and disseminating “best practices” in nursing service.
• Magnet status is based on elements of nursing practice influencing nurse attraction, retention, and quality care.
• Magnet facilities demonstrate better client quality indicators, higher satisfaction, and enhanced client communication.
• Applying involves organization-wide participation and documentation demonstrating client care outcomes, with a site visit by the Magnet survey team to make the final determination. Recognition lasts four years and can be renewed with continuous performance to standards.

Foundation of the Magnet Recognition Program

• Structural empowerment refers to administration empowering nurses to work together with community and organizational to promote those best practices.

• Exemplary professional practice means the nurse is applies new information and evidence-based practice (EBP).

• New knowledge, innovations, and improvements indicates new ideas are being formed and that EBP research is being implemented.

• Transformational leadership involves having a visionary leadership team that leads the team to learn and grow together, constantly questioning how the organization can be better.

• Empirical outcomes are the overall result of the outcomes within the organization from the workforce, client outcomes, and organizational outcomes.

• Magnet facilities reported higher support for evidence-based practice, higher client satisfaction, and higher nurse-perceived quality of care.

• Work environment is positively affected.

Pathway to Excellence Program®

• The Pathway to Excellence Program designation is awarded to health care organizations that demonstrate a commitment to providing a healthy workplace for their staff.

• The Pathway standards focus on factors that can affect nurses in the workplace—for example, turnover, workplace engagement, productivity, teamwork, and job satisfaction.

• Some benefits of the Pathway are improved nurse satisfaction, interprofessional collaboration, and the ability to champion high-quality nursing teamwork.

• The application and review process involves the frontline staff and leadership. Nurses complete a survey which validates the practices described in the application.

• Unlike the Magnet Program, there is no on-site review process for the Pathway to Excellence Program.

• The designation remains valid for four years.

• The Pathway program focuses on ensuring a supportive, proactive environment with shared governance, recruitment, retention, autonomy, and well-being.

• The Magnet program focuses more on quality outcomes and client care, nursing excellence, and the innovations nurses display and/or develop in nursing practice.

• Both programs emphasize excellence in nursing, but each has its own separate purpose.

Patient Satisfaction

• Healthcare systems focus on client satisfaction and quality care to attract clients and insurers.
• Client satisfaction influences where they choose to receive care.

Hospital Consumer Assessment of Healthcare Providers and Systems

• Acute care facilities use the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) to measure client satisfaction.
• The HCAHPS tool uses standardized questions that hospitals can use to compare their operations and outcomes to others.
• The survey includes 29 items, which includes how often a client experienced an event to whether they were satisfied with the care.
• Recently, questions about pain management, the transition to posthospital care, and experiences with admissions through the emergency department have been added to this instrument.
• The information is publicly reported and ensures the accountability and transparency of the facilities that participate.
• Within 48 hours to 6 weeks of discharge, random clients are issued a survey. Clients either receive a phone call, are mailed a survey, receive an automated message, or receive a survey in the mail with a phone-call follow-up.
• Facilities that participate in the inpatient prospective pay system (discussed in the “Insurance Reimbursements” section) have survey quotas they must achieve each calendar quarter.

Press Ganey®

• Health care facilities can use the Press Ganey® survey to evaluate healthcare delivery and client satisfaction.
• The Press Ganey survey differs from the HCAHPS survey because it includes more data regarding internal quality improvement.
• This instrument can include metrics on access to care, wait times in the clinic, and metrics regarding the interactions the client experienced with the health care team as well as the visit itself.
• Clients who visit the clinic receive a Press Ganey survey via email after the appointment.
• Receiving this type of survey following discharge encourages timely feedback.
• Current and accurate client satisfaction data can be critical to an organization’s success.

Comparing HCAHPS and Press Ganey

• HCAHPS is administered 48 hrs to 6 weeks after the visit to a random sample of clients via call, email, mail, or automated message to evaluate client satisfaction. Meanwhile, Press Ganey is used after the visit for every client via email to evaluate both health care delivery and client satisfaction

Finance, Funding, and Resource Management of Health Care Services

• Medicare, Medicaid, and Children’s Health Insurance Program

Medicare

• To qualify for coverage under the federal Medicare program, the client must be age 65 or older, younger than age 65 with disabilities, or any age with end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS).
• Medicare consists of Parts A, B, C, and D.
• The Medicare parts are structured as follows:
  • Part A covers hospitalization, skilled nursing facilities, some hospice care, some home health care
  • Part B covers doctor’s, physical therapy, occupational therapy, some home health care
  • Part C covers selected coverage that can include Medicare Parts A, B, and D
  • Part D covers extra coverage to lower costs of prescription medications
• Part A may have been paid for through the client’s taxes, but some clients may have to pay for Part A. Parts B and D have monthly premiums.

Medicaid

• To qualify for Medicaid, the client must meet eligibility requirements based on his or her income in relation to the poverty level.
• Medicaid is jointly funded and administered by the states and the federal government.
• Income eligibility varies from state to state and varies from state to state, because states form and administer the Medicaid program.
• The federal government mandates that every state must provide the following services: inpatient and outpatient hospital care, physician care, laboratory and x-ray services, transportation to receive medical care, family planning services, Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services, and home health services.
• States can choose whether they want to provide coverage for prescription drugs, case management, physical therapy, and occupational therapy.

Children’s Health Insurance Program

• The Children’s Health Insurance Program (CHIP) provides for children who may not meet Medicaid’s requirements, but need health coverage.
• The federal government provides matching funds to the states to administer this program.
• States have some flexibility in the coverage provided, but every state is mandated to provide well-baby and well-child care, dental coverage, behavioral health care, and vaccines.

Private Insurance

• Private insurance is insurance coverage that is not provided by a government agency.
• Employers may provide health insurance for their employees and pay a portion of the cost.
• There are a variety of private insurance companies through which clients may choose to obtain coverage; examples include Blue Cross Blue Shield, Cigna, Aetna, and many different health maintenance organizations (HMOs).
• Companies have a wide variety of plans and coverages to choose from and may choose several options for their employees.
• The employees can then choose the level of care they desire at a cost that is affordable for them.
• Private insurance has complex rules for reimbursement, including prior authorization, restrictions on where care can be received, and coverage limits.
• Many plans cover only a percentage of the cost, requiring clients to pay the remaining balance.
• Some companies require high deductibles (the amount that the client has to pay before the insurance company will begin payment).
• Some companies pay for prescription medications through schemes based on percentages, tiers or a flat fee.
• Navigating insurance policies is complex. Financial counselors and discharge planners can assist clients with coverage interpretation.

Insurance Reimbursements

• Historically, providers were reimbursed through a fee for service (FFS) system, based on volume rather than quality, leading to increased costs.
• Payers transitioned from paying for individual services to reimbursing for quality of care.

Diagnosis-Related Groups

• Private insurance companies in some states and the Centers for Medicare and Medicaid Services (CMS) adopted a system called diagnosis-related groups (DRGs) to help control costs.
• CMS reimburses the health care team when they provide efficient, quality care. The facility receives and accepts the same reimbursement rate no matter the client’s actual length of stay.
• DRGs code clients based on age, sex, primary diagnosis, and up to 25 additional diagnoses/procedures.
• Reimbursement is based on a set fee determined by an inpatient prospective payment system (IPPS).
• The IPPS is a formula used by CMS that determines the appropriate length of stay for all client’s who have the same DRG.
• CMS is improving its systems in an effort to ensure hospitals provide quality care to their clients.
• The Hospital-Acquired Condition Reduction Program (HACRP) which links Medicare payments to health care quality, reduces payments to facilities with poor outcomes related to hospital-acquired infections (HAIs).

Hospital-Acquired Condition Reduction Program

• If a client develops a HAI, CMS will not reimburse the facility for the costs associated with treatment for the infection and the extended stay of the client.
• Types of HAI: central line-associated bloodstream infection (CLABSI); catheter-associated urinary tract infection (CAUTI); surgical site infection (SSI): colon and hysterectomy; methicillin-resistant Staphylococcus aureus (MRSA) bacteremia; and clostridium difficile infection (CDI).
• CMS publishes HAI data for public review, enabling clients to compare infection rates between facilities.
• Assessing and reducing infection risk is crucial for nurses to ensure client safety and avoid financial risks to the organization.

Resource Utilization Groups

• The resource utilization groups (RUGs) payment system is used only in the long-term care setting (not in the acute hospital setting).
• It is another type of IPPS, whereby facilities are reimbursed based on clients’ diagnosis group and the expectation of resources to be utilized daily.
• There are seven major RUG categories: rehabilitation, extensive services, special care, clinically complex, impaired cognition, behavior problems, and reduced physical function.
• These major categories are broken down into subcategories, each of which is assigned a different Medicare payment rate, indicating the amount that the facility will be reimbursed.
• Facilities reimbursed by Medicare or Medicaid must assess clients needs at various intervals.
• The Minimum Data Set (MDS) assessment evaluates information such as the client’s cognitive status, the need for assistance with activities of daily living, and the number of treatments and therapies provided.
• This assessment determines how much CMS will reimburse the facility for the services that are provided.
• Assessments must be, thorough and accurate to ensure correct payments and interdisciplinary input and RN signatures are essential.
• Since October 2019, long-term care settings use a payment-driven patient model (PDPS), which changed the major nursing categories to extensive services, special care high/low, and clinically complex nursing categories along with detailed categories for rehabilitation.

Management of Resources

• CMS developed managed care to measure and monitor the quality of health care service delivery.
• Case managers facilitate client transfers to appropriate levels of care.
• Managed care organizations help companies control health care costs and ensure timely, appropriate care.
• Precertification is required for certain services to ensure payment.

Health Care Disparities and the Effects of Social Determinants of Health

• Each year the U.S. Department of Health and Human Services (DHHS) has developed new goals for the Healthy People program.
• This national program highlights issues that affect health promotion and disease prevention.
• The overall goals of the program address the social and physical well-being of people to ensure good health, which reflects their health care disparities, social determinants of health, and access to care.
• Some clients belong to vulnerable populations such as racial and ethnic minorities, LGBTQIA, clients who lack appropriate housing, and clients of lower socoeconomic status.
• Clients in these categories are more vulnerable to the negative impact of the SDOH.
• Disparities relate to inequalities in the health care system.
• DHHS aims to eliminate health disparities and achieve health equality.
• Healthy People 2020 defined health disparities that includes social, economic, and environmental differences, all of which affect health status.
• The meaning of wellness is not whether you have an illness present, but if you have good health.
• Factors influencing health include the physical environment, socioeconomic status, literacy levels, local and federal legislation, and availability of health services, collectively known as social determinants of health.

Social Determinants of Health

• Social determinants of health (SDOH) affect individual and population health.
• WHO drew attention to health inequities around the globe and the importance of addressing these SDOH.
• Clients are born into SDOH conditions in the environment in which they live.
• Nutrition and exercise are major influences on a person’s health and important factors in preventive health care.
• Lack of access to health care services due to financial or location limitations, preventive health care is affected.
• Five major SDOH have been identified.

Key Factors of the Social Determinants of Health

• The five SDOH, as identified by Healthy People 2030, include economic stability, education access and quality, social and community context, neighborhood and built environments, and health care access and quality.
• Healthy People 2030 further describes the determinants of health in more specific terms for social and physical determinants.
• Economically stable clients are more likely to seek medical care, eat healthy foods, obtain medications, and engaging in practices that promote health such as exercise.
• Education affects health, those with reading deficits can have an impact on overall health,
• Social and community context also has a bearing on client health from the perspective of transportation. Without a means of transportation to health care visits, the client is unable to receive health care. Lack of public transportation systems is a social determinant for this reason.
• Clients who live in crowded dwellings or poorly maintained homes are more susceptible to diseases and the lack of accessible outdoor areas promote a more sedentary lifestyle.
• Physical determinants are related to the physical environment.
• Access to health care is also critical. Transportation systems are needed to connect clients to care.
• Healthcare access includes lighting, park benches, and outdoor landscaping

Factors That Affect Social Determinants of Health

• The nurse should know how each of the underlying factors of the SDOH plays a role in a client’s health.
• The Healthy People website (www.healthypeople.gov) also provides evidence-based resources to assist the nurse in developing an approach to improve awareness and to help with education that reduces the gap in these areas.

Public Health Nurse Role

• The public health nurse plays a vital role in closing the gap in the SDOH.
• The nurse provides educational information in the community and at outpatient clinics and schools, addressing health and environmental issues that are specific to the community members.
• The public health nurse is an autonomous position, therefore, is usually held by a registered nurse with a four-year degree.

Health Care Access

• ACA implementation, insurance coverage, and broader Medicaid availability aimed to reduce disparities, some improvements in access to care have taken place in recent years, but gaps remain.
• Clients with coverage have better outcomes than those without.
• Uninsured delay care until emergency situations, leading to high costs and children without preventive care risk developmental conditions.
• The nurse can play an essential role in providing education in the community about the importance of preventive health care in improving overall well-being.

Levels of Care Across the Health Care Setting

• Clients may receive health care services in a variety of settings, depending on the severity of illness and medical care needed.
• During an episode of illness, the client may need to transfer between levels of care.
• The economic climate has been a factor that influences who clients receive care from and where care is administered.
• In many situations, care has moved from the traditional acute setting to alternative levels such as outpatient or home care settings.

Primary Care

• The primary care provider (who may be a physician, nurse practitioner, or physician’s assistant) can treat him or her for routine illness, promote wellness, and prevent disease.
• The primary care provider coordinates all the referrals, treatments, and screenings, with the goal of avoiding duplication of care.

Community Care Setting

• The community care setting also focuses on preventive services, caring for clients before admission to a facility.
• A goal in community care is to educate the community to eat better, exercise, and partake in preventive care measures to attain healthy outcomes.
• Community care settings include schools, community clinics, and voluntary organizations.

Acute Care Setting

• Acute care facilities typically have an emergency department and often surgical procedures, if required.
• Acute care facilities also have intensive care units, and some have pediatric, obstetric, and gynecologic units.
• Clients may be discharged to another facility if needed.

Long-Term Care Facility

• A long-term care (LTC) facility cares for clients who need a place to live, perhaps there are no relatives to help with care as well as family members who are unable to care for clients during their work hours.
• Most clients need assistance with activities of daily living (ADLs) such as bathing, dressing, dental hygiene, and feeding.

Skilled Nursing Facility

• A skilled nursing facility (SNF), sometimes referred to as a nursing home or LTC, may provide short-term rehabilitation care such as occupational and physical therapy as well as oversight for activities of daily living.

Long-Term Care Hospital

• A long-term care hospital (LTCH) specializes in clients who require hospitalization for long-term illnesses such as severe burns, trauma, or ventilation needs.

Assisted Living

• Assisted living care provides services for clients who are mostly independent in their living but choose to live in a community setting for assistance with some part of their daily life

Hospice Care

• Hospice care is provided to a client when the provider has determined the individual has less than six months to live.
• The client and family, along with providers, decide the goal of care is not to treat or cure the illness, but rather to provide comfort and support services.
• Hospice care covers supportive services to both the client and the family and provided in many settings.

Palliative Care

• Palliative care services provide services that help clients feel as comfortable as possible during their illness, with the goal of promoting pain relief and overall comfort during their illness.

Respite Care

• Some hospice services and some insurance companies provide for respite care.
• Respite care provides care for the client to allow the caregiver a break from these responsibilities for a short time for vacations, to travel, or to simply stay at home without caring for the client.

Home Care

• Home care services involve having a nurse or other health care providers come into the home and deliver services.
• After the initial visit, other services such as physical/occupational/speech therapy and social services may be approved, depending on the client’s needs.

Interprofessional Health Care Team Members

• In reducing errors, health care professionals' three competencies: cooperation, communication, and coordination improve health outcomes as well as reduce duplication in care.

Advanced Practice Registered Nurse

• An APRN can function as a primary care provider who can diagnose and treat clients, as well as write prescriptions and requests for consultations.
• APRNs with the appropriate specialty education may work in many specialties and can work independently.
• State laws govern APRNs’ practice, as do national certifying organizations.

Case Manager

• Case managers provide services in care coordination for the client.
• The main goal is collaborating with health care team members and the client to ensure the treatment plan meets the client’s needs and provides quality, cost-effective care.
• Case managers manage clients to help reduce the number and cost of acute services needed.

Dentist

• Dentists diagnose and treat issues within the oral cavity, including those involving the teeth, gums, and jaw.
• They function as an integral part of the interprofessional health care team, especially as clients age.

Dietitian

• Dietitians advise clients about healthy food choices for nutrition and weight management, they recommend therapeutic diets to treat specific medical conditions.

Licensed Practical Nurse

• A licensed practical nurse (LPN) has completed a state-approved program and passed a national licensure exam and works under the supervision of an RN or other provider.
• There are additional certifications that an LPN can achieve, such as intravenous therapy and gerontology care.
• Responsibilities can vary such providing basic client care, gathering data about the client’s condition, providing treatments, and administering medications.

Naturopathic Physician

• Naturopathic physicians treat clients by prescribing more natural methods such as changes in lifestyle, herbs, dietary supplements, and manipulative therapy instead of more traditional approaches to medicine.

Occupational Therapist

• OTs assist clients to either recover or develop new skills to maintain daily living and return to work.
• OTs educate clients in the use of adaptive equipment as needed to perform ADLs such as eating or ambulating, learning to navigate a household and perform household chores, cooking meals, and even paying bills.

Emergency Medical Technician

• EMTs and paramedics administer care and stabilization for clients who have emergency medical situations in the community.

Pastoral Services

• Pastoral services assist with meeting the client's/family's spiritual or religious needs. They can provide moral and spiritual guidance.

Pharmacist

• Pharmacists prepare and dispense medications prescribed by providers, educate clients on how to take medicine, and may make recommendations regarding medications and dosing.

Physical Therapist

• Physical therapists work with clients to help them improve their movement and alleviate pain utilizing exercises, stretching, and joint manipulation.

Physician

• Physicians diagnose and treat illness, prescribe medications and therapies, and interpret diagnostic testing.
• Specialists are physicians who have completed additional education in a specific field of medicine.

Physician Assistant

• Physician assistants (PAs) work under the direction and supervision of a physician, but can treat, diagnose, and prescribe medications, laboratory and other diagnostic tests, and treatments for clients.

Respiratory Therapist

• Respiratory therapists treat clients who have chronic or acute diseases of the lung.
• They manage oxygen devices and ventilator machines and conduct diagnostic testing of the lungs.

Registered Nurse

• Registered nurses (RNs) assess clients, provide and evaluate care based on that assessment, and collaborate with the interprofessional health care team to meet the client’s needs.
• RNs provide client and family teaching, administer medications, perform a wide variety of treatments, and may operate various medical equipment.
• They may oversee and delegate care to LPNs and assistive personnel.

Social Worker

• Social workers help find solutions to client challenges and advocate for resources to help resolve issues with discharge planning solutions, assisting with food stamps and insurance coverage.
• Social workers work in collaboration with the interprofessional health care team.

Speech-Language Pathologist (SLP)

- Requires at least a master's degree in speech-language pathology and licensure or certification in some states.
- The SLP evaluates and treats clients from various age groups who have speech or swallowing impairments that could be related to cognitive or social communication conditions.
- They plan the client's individual goals and teach them how to make sounds and methods to improve their vocabulary, voices, and strengthen the muscles used for swallowing.

Assistive Personnel

• Assistive personnel (AP) works under the supervision of an RN or PN and assists clients with ADLs.
• APs also obtain vital signs and fluid intake and output measurements.

Overview of the evolving U.S. health care system, regulatory standards, and the Affordable Care Act (ACA). Focus on compliance, quality, and access to care. Examines efforts to make healthcare more affordable and accessible.