2Learning ObjectivesDescribe 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.
3OrganizationHealth care system consists of patient, patient’s family, community, governmental agencies, health care providers, insurance companiesMany health services funded by government or private agenciesNot all U.S. citizens eligible for government funds; some unable or unwilling to obtain private insuranceAre all the costs of health care covered by government funding and insurance?Many people are unable to pay for care and may not receive the services they need.In the United States, about 17% of the population is uninsured.Forty-eight million (19%) of Americans under age 65 and 8.5 million (12%) of children under age 18 are uninsured.
4Managed 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
5Administration1953: Department of Health, Education and Welfare was established to organize the health and welf are agencies of the U.S. government1980: Department of Health and Human Services (DHHS) was created when education became a separate departmentToday: DHHS programs are administered by the Public Health Service and Centers for Medicare & Medicaid Services, Administration for Children and Families, and the Administration on AgingWhat is the role of the DHHS?The major activities of the Public Health Service Agencies are to:Support medical researchSupport research on health care systems, health care quality and cost issues, access to health care, and effectiveness of medical treatmentsEnsure the safety of foods and cosmeticsEnsure the safety and efficacy of drugs and medical devicesMonitor and prevent disease outbreaksProvide health services to American Indians and Alaska NativesProvide access to essential health care services for low-income uninsured persons with limited access to health careImprove substance abuse prevention, addiction treatment, and mental health servicesThe Centers for Medicare and Medicaid Services (CMS) administer the services that provide health insurance and prescription drugs for older and disabled Americans.
6Public HealthImprovement of the health of communities and aggregates (collections of people) rather than the individualMain goals are to protect and improve the health of populations at risk in the community and to prevent disease and disabilityHow are the levels of prevention traditionally classified?
7Primary Prevention To improve health; prevent disease and injury Exercise programs to increase strength and cardiovascular fitnessCampaigns in schools to prevent children from smoking and to educate people to wear seat belts
8Secondary PreventionFocuses on early detection and treatment of disease to improve patient outcomesPapanicolaou (Pap) smears and screening mammograms
9Tertiary Prevention To prevent disease recurrence or complications The use of physical therapy to prevent contractures in a stroke patientTeaching proper diet and foot care to a person with diabetes
10Financing 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 1960By 2013, projected total health care expenditures of $3.6 trillion, accounting for 18.4% of GDPLargest component of health care costs (32%) is hospital expendituresThe health care system of the United States is the most expensive in the world.What measures can be taken to control what is spent on health care?
11FinancingMany approaches to health care financing: HMOs, PPOs, and governmental agencies affect how health care is deliveredCapitation: designed to control costsHMOs pay physicians a fixed amount each month for each member (patient) enrolled in the plan, regardless of whether the physician sees the patient that monthFor the most part, health care systems have operated on a fee-for-service basis.Such coverage tends to be costly, typically requires deductions and co-payments, and has limits that may not cover actual costs.What are third-party reimbursements?
12MedicareMedicare: health insurance program offered by the U.S. government as part of the Social Security ActHelps 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 benefitsMedicare insures more than 42 million older and disabled Americans.A monthly premium is deducted from each worker’s paycheck, and the funds are matched by the federal government.What is the difference between Medicare Part A and Medicare Part B?
13Medicare Diagnosis-related groups (DRGs) Hospitals reimbursed a flat fee for specified number of days based on predetermined diagnosis fee scheduleIf the patient gets better faster, hospital makes money; if longer stay, hospital loses moneyMedicare prescription drug coverageMedicare typically pays about half an individual’s annual drug costsHistorically, hospitals billed Medicare for their costs after they were incurred, a process referred to as retrospective payment.The system changed in 1983, and since that time hospitals have been advised in advance how much they would be reimbursed for treatment of a patient with a certain condition; this is referred to as prospective payment.What if the patient doesn’t stay the number of days specified by the DRGs?
14Medicaid 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 basisStates develop and operate Medicaid programs within federal guidelinesBenefits vary from state to stateMedicaid was established in 1965 as part of the Social Security Act.Who is eligible for Medicaid?
15MedicaidBenefits provided for needy, low-income disabled individuals younger than age 65 and their dependent childrenIndividuals older than age 65 who are below a specified income level may also receive benefits, including services that Medicare does not coverWhat services are covered by Medicaid?Medicaid is more likely than Medicare to cover long-term care.Medicaid provides health coverage for nearly 45 million persons.
16Physicians OfficesPhysicians may practice in individual or group settingsMany group practices are made up of various medical specialties so that clients can have all their health care needs dealt with in one locationMany people, especially older adults, receive their primary medical care in physicians’ offices.How is the cost of visits to physicians’ offices covered?
17ClinicsOutpatient clinics are associated with community hospitals, teaching hospitals, or public health departmentsFocus on people with chronic illnesses (diabetes or heart disease) but also treat people with acute illnessesCare in clinics: diagnose and treat current illnessClinics offer physician and nursing services, rehabilitation, prenatal care, well-baby checkups, immunizations, preventive dental and eye care, laboratory and diagnostic servicesHow are clinics in large hospitals usually organized?For many people, especially older adults, specialty clinics can be a problem because older adults have many chronic illnesses and are seen in many different clinics.
19Health 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 careFederal government enacted the Health Maintenance Organization ActHelps private agencies develop methods of health care delivery to control accessibility, quality, and costBecause HMOs collect only a set fee from clients, they have an interest in promoting health and maintaining wellness.HMOs employ physicians, nurses, and other health care providers and also have a broad group of specialists available for referral.Clients are required to use only the services of the health care providers and hospitals associated with the HMO.Who was the original HMO in the United States?
20Ambulatory Care Centers Alternative to inpatient surgeryLocated in hospitals, freestanding clinics, health care centers, and physicians officesLess costly and allows people to recover in their own homesAfter recovery from anesthesia, patient is discharged, usually the same dayMany procedures such as cataract extraction, hernia repair, tonsillectomy, and the removal of foreign objects that once required hospitalization are now often performed in outpatient facilities.What is the primary criticism of outpatient surgery?
21Home Health Agencies History of home health care 1617: St. Vincent de Paul organized Daughters of CharityMembers went from house to house, taking food, education, and health care to the sickMid-1800s: William Rathbone organized first district nursing organization; opened the first training school for visiting nurses in 18591893: Lillian Wald, forerunner of modern public health nursing, founded Henry Street SettlementWho was one of the first organized groups to provide health education to the poor and to help people help themselves?Rathbone often is called the Father of the Visiting Nurses Association because he was the first to employ the district nursing concept.The Henry Street Settlement was a place where the poor could come for care and was supported by funds from the wealthy.
22Focus 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 disabilityHome health care one of fastest-growing fieldsMedical 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 homemakersFewer people are being admitted to hospitals, and they are being discharged sooner with more needs for special care.Who provides home health care?
23Funding of Home Care Services Paid for by individuals, private insurance, Medicare, and MedicaidMost nursing services paid for by Medicare must be skilled care; strict governmental guidelines define care that must be providedMedicare 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 techniquesRegulations vary from state to state but are generally patterned after federal governmental regulations.What discipline fills the case manager position for services provided in the home?
24Voluntary Agencies First to deliver nursing care in the home Financed by wealthy philanthropists in the community; mission was to care for the sick poorVisiting Nurses Association: most common example of a voluntary agencyUsually governed by a community board of directors that determines service delivery policies and assists with fund-raisingBecause board members are drawn from different areas and social strata within the community, services often reflect community needs.Where does funding for voluntary agencies usually come from?
25Official AgenciesSupported by tax dollars; authorized by law to deliver services to a defined area or communityState, regional, and local health departments are responsible for health promotion and disease prevention services, communicable disease investigation, environmental health protectionIn most states, includes maternal and child services, sexually transmitted infection clinics, tuberculosis surveillance and treatment, and other health services as funds permit
26Proprietary Agencies Organized to make a profit on their operation May or may not participate in Medicare; most doMay be owned by individuals or corporate chainsLimitations imposed by the Balanced Budget Act (1997) decreased profitability, and many have closedWhat are the sources of revenue for proprietary agencies?The prospective payment system contributed substantially to the growth of home health care.
27Hospital-Based Agencies Usually governed by hospital’s board of directorsMost referrals from the hospital itselfPhilosophy and policies usually consistent with those of parent institutionHospitals that were losing money under the prospective payment system saw the opportunity to recoup lost profits by opening home health agencies.Who usually governs the hospital-based agencies?
29Home Health Care Services Physical therapyFor patients recovering from health problems affecting mobility, such as hip fractures and strokesPhysical therapists assess need for walkers, wheelchairs, and grab bars and work with patients on therapies to regain strength and mobilityWhat are the requirements for a patient to receive services in the home?
30Home Health Care Services Speech therapySpeech therapists work with patients who have speech or swallowing disordersA common indication for speech therapy is aphasiaTo receive speech therapy in the home that is reimbursed by Medicare, it is necessary to meet all of the criteria for Medicare.
31Home Health Care Services Occupational therapyFor conditions that impair upper-extremity movementPeople with arthritis or stroke may benefit from assistive devices for dressing and other daily personal care and household activitiesOccupational therapists also provide muscle reeducation, splinting, and improved control of fine motor movementTimely occupational therapy can help the patient become safer and more independent in the home
32Home Health Care Services Social workersProvide valuable assistance to families trying to manage chronic illness in the homeWork with families to identify problems that arise in managing illness at home and recommend referrals to community resourcesMay provide information about financial assistance and help with applications for community services such as Meals-on-Wheels and respite care
33Home Health Care Services Home health aide servicesProvide personal care, such as bathing, ambulating, transferring, skin care, and oral hygiene, for the patient in the homeMeasure and record vital signs and do other basic, nonskilled tasksHomemaking tasks, such as making the bed and straightening the client’s room, are also common home health aide servicesWhat services are inappropriate for home health aides?Patients qualify for home health services if they already receive one of the three primary skilled services.
34Home Health Care Services Homemaker servicesUsually provided by families or state and local assistance programsDuties include common household chores, such as cooking, light housekeeping, laundry, shopping, and picking up medications
35Home Health Care Services Enterostomal therapySpecialists in the care of all types of wounds, such as pressure ulcers, surgical wounds, and ostomiesProvide care to patients and consultation to nurses on how to manage woundsExtensive knowledge of skin care products and ostomy appliances
36Home Health Care Services Other home health care service providersDietitiansNurse practitionersPsychologists
37Home Health Care Services Specialty home care servicesPediatric: small, compact pumps, ventilators, and monitors have enabled children with cancer, respiratory disease, and cerebral palsy to live more normal lives at homeMental health: provide medication monitoring and teaching and perform mental status examinations and suicide assessmentsProspective payment systems and the use of DRGs have provided a stimulus for the development of specialty home care, especially for pediatric, psychiatric, and terminally ill patients.Why are insurance companies becoming more interested in funding pediatric home care?
38HospiceMay be delivered in the home, acute care hospital, or extended care facilityProvide care for terminally ill patients in the home and other specified facilitiesPurpose: enable terminally ill patients to live as full a life as possible, with skilled personnel managing pain, discomfort, and other symptoms associated with the illnessThe hospice concept is a concept of caring that originated in fifteenth-century Europe as the provision of respite and comfort for travelers.Later this concept was extended to the dying in both hospitals and home settings.What are the requirements for admission to hospice care?
39Adult Daycare Centers Services and activities Promote health and socializationBenefit the elderly and mentally illMay be associated with hospitals or nursing homes, or function independentlyAllow older people to live supervised in the community during the day while the family is at workCenters provide health-related services, health promotion programs, nutritional meals, and social activitiesFees are based on a sliding scale fee or freeMany of the services provided at day care centers are funded through the Older Americans Act, which was originally passed in 1965.Mental health services are also offered through day care.People who need counseling, follow-up care after hospitalization, and rehabilitation related to chemical dependence may benefit from day care programs.What is the Older Americans Act of 1965?
41Hospitals 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 organizationsMost 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 dischargeHospital care accounts for about 40% of personal health care expenditures in the United States.The predominant sources of payment for hospital services are Medicare (34%), Medicaid (22%), and private insurance (36%).About 5% of all hospitalizations are not covered by any type of insurance.Transitional hospitals receive patients with acute but stable conditions who will need a lengthy minimum stay (often 25 days).What are subacute care units?
43Psychiatric 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 hospitalMay be private, nonprofit organizations that are sponsored by organized churches or run by local, state, or federal governmentsThe cost of care is covered by most private insurance companies.How long will private insurance companies cover services in a psychiatric hospital?
44Rehabilitation Centers Restore individuals to former level of functioning or maintain or maximize remaining functionLocated within the hospital or nursing home or in a freestanding residential institutionMay 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 illnessRehabilitation can and should be carried out in all health care settings by a variety of health care professionals with the active involvement of patients and their families.Who makes up the rehabilitation team?
46Long-Term Care Facilities Originally described institutions attached to hospitals for recovery from acute illnessNow describe several different kinds of institutions—nursing homes, convalescent homes, and some residential institutions—whose primary purpose is caring for people with chronic illnesses and physical impairmentsFocus is on those who do not need hospitalization but cannot care for themselvesModern long-term care for the elderly and disabled had its beginnings in nursing home care, which dates back at least to the turn of the twentieth century.What type of standards did long-term care have when it first began?Later, nursing home care became tied to the medical care system, and the nursing home increasingly became a place for patients needing skilled nursing and social services.
48Long-Term Care Facilities Independent living retirement centersOffer services that permit residents to access the level of care needed at a given point in timeBoarding and personal care homesProvide a room and meals and, in some cases, minimal assistance and supervisionResidents of these facilities usually come and go as they please
49Long-Term Care Facilities Assisted living facilitiesPermit a high degree of independence but usually have limited access to nursing careHelp with medications; some treatments may be providedResidents often have kitchens; some group meals are typically provided
50Long-Term Care Facilities Intermediate-care skilled nursing facilityProvides care from a licensed nursing staff, including rehabilitation for people who can regain functionServices: medical and nursing care; physical rehabilitation; long-term ventilator care; wound care; pharmaceutical, dietary, and social services; dental care; and activitiesFederal regulations require an RN to serve as director of nursing and an LPN to be on duty at least 8 hours a dayThis level of care is also referred to as extended care.What type of nursing care is provided at an intermediate-care facility?
51Skilled 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 dressingsCan residents in need of custodial care receive benefits at a skilled nursing facility under Medicare?A skilled nursing facility must have skilled health professionals available around-the-clock.A skilled nursing facility requires physician supervision and the services of a registered nurse, physical therapist, or speech therapist.