206 - chapter 6 PDF

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Lecture Notes for Chapter 6 of Kozier and Erbs...

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208 – Essentials Chapter 6 – Health Care Delivery Systems What is a health care system?  The sum of all services offered by all health care disciplines  Focus in the past was treating an ill patient  The focus now is trending towards illness prevention o We are now focusing on health promotion. o Health promotion is beneficial cost wise in the long run o So much money is spent on patients trying to maintain their health rather than trying to prevent certain conditions (which they are now paying for) Health Care services:  Categorized by type and level o Primary prevention – health promotion, illness -revention o Secondary prevention – diagnosis, tx of disease, screenings for something that is already there for that there is family history of. o Tertiary prevention – rehabilitation, health restoration, palliative care.  Nurses are advocates for our patients  Patients need to be invested and take an active role in their own healthcare  Encourage patients to maintain the highest level of wellness they can achieve.  Prevention can be directed towards an individual, group of individual or community. Healthy People  Developed by the world health organization  Periodically updated: currently working on healthy people 2030  Goals of healthy people 2020 o Increase the quality and years of healthy life o Achieve health equity and eliminate disparities o Create healthy environments for everyone o Promote health and quality across the life span Secondary Prevention:  Diagnosis and treatment  Early detection of diseases (mammograms, HIV screenings, PPD)  Giving patient medications Tertiary Prevention:  Moving patients from the current status when they are ill to highest level they can achieve  Rehabilitative care (physical, social, economic, vocational)  Restoration of health

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Outreach programs in the community to make sure patients are taking their medications Palliative care: o When we cannot restore them to functional health o Provides comfort and treatment o End of life care (home, hospice centers)

Types of health care agencies and services:  Public health (federal, state and local) o Local health departments, CDC, PHS, dept of health  Provider offices o NP, PA, MD o Routine health screenings, illness diagnosis and tx  Ambulatory care centers o Walk in clinics that do diagnosis and treatment o Redimed, health stops  Occupational health clinics o Run by companies o Health promotion (TB screenings, work safety , health education_  Hospitals: o Inpatient, outpatient, and ambulatory care, hospice (palliative care)  Sub acute care facilities o Complex treatments o Provide an inpatient setting  Extended long term care facilities (LTC) o Formerly known as nursing homes (provide long term care) o Skilled nursing facilities (SNF – provide immediate care) o Receive rehab here, dressing changes, IV antibiotics etc  Retirement/assisted living centers: o Independent communal living, but some services such as meals, laundry, minimal nursing care, transportation and social activities are provided  Home Care Agencies o Care within the home  Rehabilitation centers o Drug and alcohol, or physical rehab o Rehabilitation – ideally starts the moment a patient enters the health care system – from the moment they enter we are creating a plan for discharge  Day care centers o Adult day care (respite care): for those who cannot be left alone but do not need a long term care facility o Often used for dementia/Alzheimer’s patients because it can be taxing on the caregiver

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The care giver may need to go to work or perform some errands in which the patient can not be left alone during.

Rural care o Care for individuals who cannot get into urban high use areas o NP generalists o Receive federal funding to remain open o Affordable care act provides funding for these community programs Hospice: o Client and family - must have indication of “dying” within 6 months to qualify o May be at home, Skilled nursing facility, hospitals, hospice centers o Doesn’t just cover the person dying, but helps to cover the family for a whole year following the death, in some cases cards are sent, the hospice may keep in contact with family o Theyre not treating the patient for what they are coming in for (cancer) but they will provide care for a secondary illness such as a UTI while in the facility – they provide comfort needs for the patients. Mutual support and health groups o Alcoholics anonymous, narcotics anonymous

Providers of Health care:  Nurse  Case manager  Dentist  Dietician – nutritionist  Emergency medical personnel – EMT, first responders  Alternative (complementary)care provider – massage therapy, holistic health, acupuncture, chiropractor  Occupational therapist  Pharmacist  PT  Physician  NP/PA  Podiatrist  Respiratory therapist  Social worker  UAP – unlicensed assistive personnel – performs delegated basic client care o May have a standardized education o Directed by a nurse o Part of the TEAM Factors Affecting Health Care delivery  Increasing number of older adults – more expensive to take care of

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o There is substantial home management, nursing support services required o Expensive because of chronic illnesses Advanced technology o New procedures/medications o Bedside charting and computers o Costly Economics o Health spending predicted to increase substantially after affordable care act o Cost increases, mostly in outpatient and prescriptions Uneven distribution of services o Increased specialization o Lowest numbers of nurses in the southwest US Access to health insurance o Those without insurance are often diagnosed later in illnesses o Those with greatest need for care often least able to pay for it The homeless and the poor o General poor health exacerbated o Lack of convenient, timely transportation HIPPA – Health insurance portability and accountability Act o Regulations to protect privacy of individuals including electronic health records o Clients provided with notice Demographic changes o Culturally competent, diverse clients o Increasing alternative family structures

Frameworks for Care  Managed Care o Health care system whose goals are to provide cost-effective, quality care with decreased costs and improved outcomes for groups of patients o Customer satisfaction o Preventive services  Case management: o Range of models for integrating health care services o Critical pathways  A plan that tracks the clients progress Payment sources in the United States  Health care agencies receive funding from several available sources o Medicare o Medicaid o Private insurance

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o Out of pocket MEDICARE: o For adults over 65 and people who are under 65 but are permanently disabled o Part A – provides Hospital care, home care and hospice o Part B – provides partial outpatient and physician services (this portion of the plan is voluntary) o Part C – advantage plans o Part D – prescription plan (voluntary) o Coinsurance (20%) and deductible applies o Does not cover dental, eyeglasses, hearing aids, etc. o Fully disabled person who receive social security do get medicare despite their age o Elders often purchase private supplemental insurance (AARP, BCBS medicare ect) o Medicare limits the amount paid to hospitals that are reimbursed by medicare o Diagnosis-related groups DRGs o Categorized and standardized patient care into groups to organize payments MEDICAID o Federal financial assistance for those with low income o Each state is distinct o Medicaid covers the 20% of medicare coinsurance portion is patient has both coverages Supplemental Security income o SSI benefits people with disabilities o For those not eligible for Social Security Children’s Health insurance program (CHIP) o Insurance coverage for poor and working class children o Includes primary care, prescriptions, hospitalizations Women, infants and children program (WIC) o Income driven – financial based need o Nutritional foods to supplement diets o Information on health eating o Referrals to health care o Mothers and children up to age 5 Private Insurance o Third party reimbursement o Provide blanket medical service in exchange for monthly payment o Health maintenance organization (HMO)  Emphasizes client wellness  Limited selection of providers/services

 Reduced, predetermined costs  Goes by networks for certain facilities  Requires referrals from PCP for specialty care o Preferred Provider Organizations (PPO)  Choice of health care providers, services – go to any office  Tend to be more expensive than HMO o Preferred provider arrangements  Typically cannada  Can be contracted with individual health care providers  Can be limited or unlimited  Paid out of pocket...