Chapter 2 part 1 U.S. Healthcare System

U.S. Health Care System

• Complex and constantly changing
• Focus on reducing costs, improving access, and ensuring high-quality outcomes
• 30 million Americans lacked health insurance in 2020 (Assistant Secretary for Planning and Evaluation, 2021)
• Health care expenditures in the United States totaled 17.7% of the gross domestic product in 2018, averaging $11,172 per person (Centers for Medicare and Medicaid Services, 2019a)

Nursing Profession

• Rooted in helping people regain, maintain, or improve their health
• Focus on preventing illness and finding comfort and dignity at the end of life
• Nursing promotes health, well-being, comfort, dignity, and humanity of all individuals, families, groups, communities, and populations (American Nurses Association, 2021)
• Challenges facing nursing include:
  • Aging baby boomer generation
  • Shortage and uneven distribution of physicians
  • Accelerating rate of nurses' retirements
  • Uncertainty of health care reform

Levels of Health Care

• Six levels of care:
  • Preventive care
  • Primary care
  • Secondary care
  • Tertiary care
  • Restorative care
  • Continuing care
• Each level presents different requirements and opportunities for nurses
• Levels of care are not the same as levels of prevention (see Chapter 6)

Integrated Health Care Delivery

• Developed as part of the U.S. health care reform movement
• Aims to provide a continuum of health services to a defined population
• Goals include:
  • Improving health care quality
  • Decreasing overall health care costs
  • Focusing on population health
• Examples include:
  • Accountable Care Organizations (ACOs)
  • Patient-Centered Medical Home model

Primary and Preventive Health Care Services

• Primary health care focuses on improved health outcomes for an entire population
• Primary health care services include:
  • Regular health care visits
  • Health education
  • Proper nutrition
  • Maternal/child health care
  • Family planning
  • Immunizations
  • Control of diseases
• Health promotion programs are designed to reduce the incidence of disease and minimize complications

Secondary and Tertiary Care

• Secondary health care is provided by a specialist or agency on referral by a primary health care provider
• Tertiary health care is specialized consultative care, usually provided on referral from secondary medical personnel
• Examples of secondary and tertiary care include:
  • Hospital emergency care
  • Intensive care units (ICUs)
  • Specialty care (e.g., cardiology, neurology, oncology)### Clinics and Community Centers
• Clinics are often associated with schools, colleges, departments of nursing, federally qualified health centers, or independent nonprofit health care agencies.
• Services provided by clinics include:
  • Diabetes screenings
  • Smoking cessation programs
  • Immunizations
  • Physical examinations
  • Cardiovascular checks
  • Health risk appraisal
  • Wellness counseling
  • Employment readiness
  • Acute and chronic care management
• Community centers provide comprehensive and cost-effective primary care and supportive services to promote access to health care.
• Services provided by community centers include:
  • Physical assessment and health screening
  • Nutrition education
  • Translation services
  • Dental care
  • Mental health services
  • Care coordination and case management
  • Specialty care (e.g., orthopedic, cardiac, or podiatric care)
  • Disease management
  • Health education

Mental Health Services

• Mental health facilities are located in hospitals, independent outpatient clinics, and private mental health hospitals.
• Services provided by mental health facilities include:
  • Inpatient and outpatient services
  • Voluntary and involuntary admission
• Patients who are hospitalized usually have short stays intended to stabilize them before transfer to outpatient treatment centers.
• Patients with mental illness receive a comprehensive interprofessional treatment plan that engages patients and their families.

Rural Hospitals

• Rural hospitals face challenges in providing access to health care due to factors such as:
  • Economic factors (e.g., poverty)
  • Cultural and social differences
  • Educational shortcomings
  • Lack of recognition by legislators
  • Isolation from living in remote rural areas
• To address these challenges, some rural hospitals have been designated as Critical Access Hospitals (CAHs).
• CAHs provide 24/7 emergency services, have no more than 25 inpatient beds, and report an average length of stay (LOS) of 96 hours or less.

Discharge Planning

• Discharge planning is a coordinated, interprofessional process that develops a plan for continuing care after a patient leaves a health care agency.
• The focus of discharge planning is to ensure that a patient transitions to the setting in which health care needs can be appropriately met.
• Elements of discharge planning include:
  • Determining the appropriate post-hospital destination for a patient
  • Identifying a patient's needs for a smooth and safe transition
  • Beginning the process of meeting a patient's needs while the patient is still hospitalized
• Discharge instructions prepare patients for transition from a hospital to the next level of care.
• Patients and family caregivers are involved in the decisions about the patient's discharge destination.

Restorative Care

• Restorative care helps patients regain maximal functional status and enhance quality of life through promotion of independence and self-care.
• Goals of restorative care include:
  • Regaining functional status
  • Enhancing quality of life
• Restorative care settings include:
  • Home care
  • Rehabilitation centers
  • Skilled nursing facilities
• The restorative health care team is interprofessional and includes the patient and family or significant others.

Home Care

• Home care is the provision of medically related professional and paraprofessional services and equipment to patients and families in their homes.

• Services provided by home care include:

  • Part-time, medically necessary skilled care (e.g., nursing, physical therapy, occupational therapy, and speech-language therapy)
  • Coordination of access to and delivery of home health equipment
  • Health maintenance, education, illness prevention, diagnosis, and treatment of disease, rehabilitation, and palliative care### Home Care Nursing

• Home care nurses deliver highly individualized nursing care to patients with permanent or temporary physical limitations, enabling them to adapt to a daily home routine.

• Home care requires a strong knowledge base in many areas, including family dynamics, cultural competence, spiritual values, and communication principles.

• Nurses who work in Medicare-certified home care agencies conduct patient-specific comprehensive assessments at various points, including the start of care, 60-day follow-ups, discharge, and before and after an inpatient stay.

• The comprehensive assessment, OASIS (Outcome and Assessment Information Set), includes standardized core assessment items for an adult home care patient.

OASIS Assessment

• OASIS forms the basis for measuring patient outcomes and improving home health care for the purposes of outcome-based quality.
• Data items within OASIS include sociodemographic information on the patient's home environment and informal caregivers, support system, health status, functional status, psychosocial status, and health service utilization.

Home Health Care

• Home health care focuses on the goal of helping patients and their family members achieve independence.
• Home care addresses the recovery from and stabilization of an illness, identifies problems related to lifestyle, safety, environment, family dynamics, and health care practices.
• Home care agencies provide skilled and intermittent professional services, such as wound care, administration of medications and blood therapy, and home care aide services.

Rehabilitation

• The World Health Organization (WHO) defines rehabilitation as the process aimed at enabling people with disabilities to reach and maintain their optimal physical, sensory, intellectual, psychological, and social functional levels.
• Rehabilitation gives people with disabilities the tools they need to attain independence and self-determination.
• Patients require rehabilitation after a physical or mental illness, surgery, injury, or chemical addiction.
• The goal of rehabilitation services is to help patients and families adjust to necessary changes in lifestyle and learn to function with the limitations of their disease.

Rehabilitation Services

• Rehabilitation services include physical, occupational, and speech therapy, and social services.
• Rehabilitation begins the moment a patient enters a health care setting for treatment, focusing on preventing complications related to an illness or injury, and then maximizing functioning and level of independence.
• Rehabilitation settings include rehabilitation units within acute care centers, freestanding outpatient settings, and the home.

Extended Care Facilities

• Extended care facilities provide intermediate medical, nursing, or custodial care for patients recovering from acute illness or those with chronic illnesses or disabilities.
• Extended care facilities include intermediate care and skilled nursing facilities, long-term care and assisted-living facilities.
• In the past, extended care facilities primarily cared for older adults, but now they provide care for patients of all ages due to the focus on early discharge from hospitals.

Nursing Centers or Facilities

• Nursing centers or facilities provide 24-hour intermediate and custodial care, including nursing, rehabilitation, dietary, recreational, social, and religious services for residents of any age with chronic or debilitating illnesses.
• Nursing center services provided by Medicaid-certified nursing homes offer skilled nursing, rehabilitation, and long-term care.
• Nursing centers must comply with the Omnibus Budget Reconciliation Act of 1987 and its minimum requirements for nursing facilities to receive payment from Medicare and Medicaid.