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1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Chapter 1 The Health Care System
2Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Learning Objectives Describe the organization of the health care system in the United States. Describe the focus of public health services. Define the three levels of prevention. Discuss financing of health care in the United States, including Medicare and Medicaid programs. Describe the components of the health care system that provide outpatient and inpatient care and the types of service each provides. Describe the impact of cost-containment measures on the delivery of care.
3Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Organization Health care system consists of patient, patients family, community, governmental agencies, health care providers, insurance companies Many health services funded by government or private agencies Not all U.S. citizens eligible for government funds; some unable or unwilling to obtain private insurance
4Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Managed Care Provides comprehensive health care at a reasonable cost Health maintenance organization (HMO) Preferred provider organization (PPO) Managed care has stimulated increased interest in wellness and prevention, increased outpatient and home health care, and increased cost sharing
5Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Administration 1953: Department of Health, Education and Welfare was established to organize the health and we lf are agencies of the U.S. government 1980: Department of Health and Human Services (DHHS) was created when education became a separate department Today: DHHS programs are administered by the Public Health Service and Centers for Medicare & Medicaid Services, Administration for Children and Families, and the Administration on Aging
6Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Public Health Improvement of the health of communities and aggregates (collections of people) rather than the individual Main goals are to protect and improve the health of populations at risk in the community and to prevent disease and disability
7Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Primary Prevention To improve health; prevent disease and injury Exercise programs to increase strength and cardiovascular fitness Campaigns in schools to prevent children from smoking and to educate people to wear seat belts
8Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Secondary Prevention Focuses on early detection and treatment of disease to improve patient outcomes Papanicolaou (Pap) smears and screening mammograms
9Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Tertiary Prevention To prevent disease recurrence or complications The use of physical therapy to prevent contractures in a stroke patient Teaching proper diet and foot care to a person with diabetes
10Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Financing U.S. health care most expensive in the world In 2002, $1.6 trillion (equal to 14.9% of gross domestic product [GDP]) spent on health care, compared with 5% in 1960 By 2013, projected total health care expenditures of $3.6 trillion, accounting for 18.4% of GDP Largest component of health care costs (32%) is hospital expenditures
11Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Financing Many approaches to health care financing: HMOs, PPOs, and governmental agencies affect how health care is delivered Capitation: designed to control costs HMOs pay physicians a fixed amount each month for each member (patient) enrolled in the plan, regardless of whether the physician sees the patient that month
12Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Medicare Medicare: health insurance program offered by the U.S. government as part of the Social Security Act Helps pay for health care of people ages 65 and older, those of any age with permanent kidney failure, and those younger than age 65 who qualify for Social Security disability benefits
13Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Medicare Diagnosis-related groups (DRGs) Hospitals reimbursed a flat fee for specified number of days based on predetermined diagnosis fee schedule If the patient gets better faster, hospital makes money; if longer stay, hospital loses money Medicare prescription drug coverage Medicare typically pays about half an individuals annual drug costs
14Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Medicaid Government insurance program for people of very low income Funded by federal, state, and local taxes; administered by federal and state governments on a partnership basis States develop and operate Medicaid programs within federal guidelines Benefits vary from state to state
15Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Medicaid Benefits provided for needy, low-income disabled individuals younger than age 65 and their dependent children Individuals older than age 65 who are below a specified income level may also receive benefits, including services that Medicare does not cover
16Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Physicians Offices Physicians may practice in individual or group settings Many group practices are made up of various medical specialties so that clients can have all their health care needs dealt with in one location
17Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Clinics Outpatient clinics are associated with community hospitals, teaching hospitals, or public health departments Focus on people with chronic illnesses (diabetes or heart disease) but also treat people with acute illnesses Care in clinics: diagnose and treat current illness Clinics offer physician and nursing services, rehabilitation, prenatal care, well-baby checkups, immunizations, preventive dental and eye care, laboratory and diagnostic services
18Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 1-1
19Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Health Maintenance Organizations Group practice with prepayment, voluntary enrollment, combination of hospital and outpatient facilities, emphasis on health promotion and illness prevention, and physician responsibility for direction of patient care Federal government enacted the Health Maintenance Organization Act Helps private agencies develop methods of health care delivery to control accessibility, quality, and cost
20Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Ambulatory Care Centers Alternative to inpatient surgery Located in hospitals, freestanding clinics, health care centers, and physicians offices Less costly and allows people to recover in their own homes After recovery from anesthesia, patient is discharged, usually the same day
21Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Home Health Agencies History of home health care 1617: St. Vincent de Paul organized Daughters of Charity Members went from house to house, taking food, education, and health care to the sick Mid-1800s: William Rathbone organized first district nursing organization; opened the first training school for visiting nurses in : Lillian Wald, forerunner of modern public health nursing, founded Henry Street Settlement
22Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Focus of Home Health Care Services for clients in their homes or assisted living centers: promote, maintain, or restore health or minimize the effects of illness and disability Home health care one of fastest-growing fields Medical and dental care, nursing care, physical and occupational therapy, speech therapy, enterostomal therapy, social work, nutrition counseling, transportation, lab services, medical equipment and supplies, and the assistance of home health aides and homemakers
23Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Funding of Home Care Services Paid for by individuals, private insurance, Medicare, and Medicaid Most nursing services paid for by Medicare must be skilled care; strict governmental guidelines define care that must be provided Medicare regulations for home care identify standard duties of the LPN, including furnishing health services, preparing progress notes, assisting the RN in special procedures, and assisting the patient in learning self-care techniques
24Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Voluntary Agencies First to deliver nursing care in the home Financed by wealthy philanthropists in the community; mission was to care for the sick poor Visiting Nurses Association: most common example of a voluntary agency Usually governed by a community board of directors that determines service delivery policies and assists with fund-raising
25Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Official Agencies Supported by tax dollars; authorized by law to deliver services to a defined area or community State, regional, and local health departments are responsible for health promotion and disease prevention services, communicable disease investigation, environmental health protection In most states, includes maternal and child services, sexually transmitted infection clinics, tuberculosis surveillance and treatment, and other health services as funds permit
26Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Proprietary Agencies Organized to make a profit on their operation May or may not participate in Medicare; most do May be owned by individuals or corporate chains Limitations imposed by the Balanced Budget Act (1997) decreased profitability, and many have closed
27Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Hospital-Based Agencies Usually governed by hospitals board of directors Most referrals from the hospital itself Philosophy and policies usually consistent with those of parent institution
28Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Outpatient Care
29Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Home Health Care Services Physical therapy For patients recovering from health problems affecting mobility, such as hip fractures and strokes Physical therapists assess need for walkers, wheelchairs, and grab bars and work with patients on therapies to regain strength and mobility
30Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Home Health Care Services Speech therapy Speech therapists work with patients who have speech or swallowing disorders A common indication for speech therapy is aphasia
31Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Home Health Care Services Occupational therapy For conditions that impair upper-extremity movement People with arthritis or stroke may benefit from assistive devices for dressing and other daily personal care and household activities Occupational therapists also provide muscle reeducation, splinting, and improved control of fine motor movement Timely occupational therapy can help the patient become safer and more independent in the home
32Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Home Health Care Services Social workers Provide valuable assistance to families trying to manage chronic illness in the home Work with families to identify problems that arise in managing illness at home and recommend referrals to community resources May provide information about financial assistance and help with applications for community services such as Meals-on-Wheels and respite care
33Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Home Health Care Services Home health aide services Provide personal care, such as bathing, ambulating, transferring, skin care, and oral hygiene, for the patient in the home Measure and record vital signs and do other basic, nonskilled tasks Homemaking tasks, such as making the bed and straightening the clients room, are also common home health aide services
34Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Home Health Care Services Homemaker services Usually provided by families or state and local assistance programs Duties include common household chores, such as cooking, light housekeeping, laundry, shopping, and picking up medications
35Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Home Health Care Services Enterostomal therapy Specialists in the care of all types of wounds, such as pressure ulcers, surgical wounds, and ostomies Provide care to patients and consultation to nurses on how to manage wounds Extensive knowledge of skin care products and ostomy appliances
36Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Home Health Care Services Other home health care service providers Dietitians Nurse practitioners Psychologists
37Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Home Health Care Services Specialty home care services Pediatric: small, compact pumps, ventilators, and monitors have enabled children with cancer, respiratory disease, and cerebral palsy to live more normal lives at home Mental health: provide medication monitoring and teaching and perform mental status examinations and suicide assessments
38Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Hospice May be delivered in the home, acute care hospital, or extended care facility Provide care for terminally ill patients in the home and other specified facilities Purpose: enable terminally ill patients to live as full a life as possible, with skilled personnel managing pain, discomfort, and other symptoms associated with the illness
39Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Adult Daycare Centers Services and activities Promote health and socialization Benefit the elderly and mentally ill May be associated with hospitals or nursing homes, or function independently Allow older people to live supervised in the community during the day while the family is at work Centers provide health-related services, health promotion programs, nutritional meals, and social activities Fees are based on a sliding scale fee or free
40Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Inpatient Care
41Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Hospitals Vary greatly in size, shape, and organization Some hospitals are public and financed by the local, state, or federal government; others are private and owned by churches, businesses, corporations, or charitable organizations Most frequent reasons for hospitalization are infant delivery, cardiovascular disease, chest pain, pneumonia, and depression Transitional and subacute facilities provide intermediate levels of care after hospital discharge
42Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 1-3
43Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Psychiatric Hospitals Inpatient and outpatient treatment for acute psychiatric illnesses; focus on helping clients control their behavior or restore their behavior to what it was before entering the hospital May be private, nonprofit organizations that are sponsored by organized churches or run by local, state, or federal governments
44Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Rehabilitation Centers Restore individuals to former level of functioning or maintain or maximize remaining function Located within the hospital or nursing home or in a freestanding residential institution May focus on physical problems, such as those caused by stroke, spinal cord injury, or amputation, or on mental health problems, such as drug dependency or mental illness
45Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 1-4
46Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Long-Term Care Facilities Originally described institutions attached to hospitals for recovery from acute illness Now describe several different kinds of institutionsnursing homes, convalescent homes, and some residential institutions whose primary purpose is caring for people with chronic illnesses and physical impairments Focus is on those who do not need hospitalization but cannot care for themselves
47Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 1-2
48Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Long-Term Care Facilities Independent living retirement centers Offer services that permit residents to access the level of care needed at a given point in time Boarding and personal care homes Provide a room and meals and, in some cases, minimal assistance and supervision Residents of these facilities usually come and go as they please
49Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Long-Term Care Facilities Assisted living facilities Permit a high degree of independence but usually have limited access to nursing care Help with medications; some treatments may be provided Residents often have kitchens; some group meals are typically provided
50Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Long-Term Care Facilities Intermediate-care skilled nursing facility Provides care from a licensed nursing staff, including rehabilitation for people who can regain function Services: medical and nursing care; physical rehabilitation; long-term ventilator care; wound care; pharmaceutical, dietary, and social services; dental care; and activities Federal regulations require an RN to serve as director of nursing and an LPN to be on duty at least 8 hours a day
51Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Skilled Nursing Facility Residents must be in need of care that consists of observation during an acute or unstable phase of an illness, administration of enteral (tube) feedings or IV fluids, bowel and bladder retraining (for a limited period), administration of intramuscular or intravenous medications, or changing of sterile dressings
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