1. The Health Care Delivery System
Chapter 2
NUR 215
Professor Stewart

2. What is a Health Care Delivery System?
It is a mechanism for providing services that meet the health-related needs of individuals.
Nursing is a major component of the U.S. health care delivery system.
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3. Organizational Framework
Public Sector (includes official and voluntary)
Private Sector
No single agency or group controls the entire health care system.
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4. Public Sector Federal Level (DHHS) State Level (Dept. of Health)
Local Level Health Units
Environ-mental Health and Safety
Health Records Mainten-ance (Vital Statistics)
Individual Health Services
Public Health Education
Commun-icable Disease Control
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Private Sector
Largest segment of the health care system (most healthcare facilities are run by private for-profit or not-for-profit corporations)
Also includes health insurance industry, pharmaceutical companies, suppliers of health care technology and equipment
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6. Reimbursement Methods
Private Insurance
Managed Care
Health Maintenance Organizations (HMOs)
Preferred Provider Organization (PPO)
Federal government insurance plans
Medicare
Medicaid
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Managed Care
Goal: The delivery of services in the most cost-efficient manner possible.
Seeks to control costs by monitoring delivery of services and restricting access to expensive procedures and providers.
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Managed Care (cont.)
Health Maintenance Organizations (HMOs)
Capitated Rates
Primary care providers (“Gate-keepers”)
Preferred Provider Organizations (PPO)
Networks
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9. Federal Government Plans
Medicare – for older adults and people with disabilities
Diagnosis-related groups (DRGs)
Medicaid – For the economically disadvantaged
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Health Care Today
Primary Care Provider Limitations
Referrals
Decreased Hospitalization
Care at Home
Less Service Oriented and More Business Oriented
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11. Is health care a right or a privilege?

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Levels of Health Care
Primary
Secondary
Tertiary
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Primary Care
Goal – To decrease the risk to client for disease or dysfunction
Focus – General Health Promotion; Protection against specific illnesses
Examples: Teaching, Lifestyle Promotion, Immunizations
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Primary Care Settings
School health services
Occupational health services
Physicians’ offices
Clinics
Nursing centers
Block and parish nursing
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Secondary Care
Goal: Early intervention to alleviate disease and prevent further disability
Focus: Early detection and intervention
Examples: Screening, diagnosis, acute care, surgery
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Secondary Settings
Hospitals/medical centers
Emergency departments
Medical units
Intensive care
Psychiatric facilities
Rural hospitals
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Tertiary Care
Goal: To minimize effects of and permanent disability due to chronic or irreversible condition
Focus: To restore and rehabilitate to obtain optimal level of function
Examples: Education and retraining; Environmental modifications
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18. Tertiary Care Settings
Home health care
Rehabilitation centers
Extended care facilities
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Health Care Team
Nurse (RN)
Physician (MD, DO)
Physician assistant (PA)
Pharmacist (RPh)
Dentist (DDS, DMD)
Dietitian (RD)
Social worker (SW)
Respiratory therapist (RT)
Physical therapist (PT)
Occupational therapist (OT)
Chaplain
Unlicensed assistive personnel (UAP)
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Roles of the Nurse
Caregiver
Teacher
Advocate
Manager
Expert
Case manager
Team member
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21. Nurses and the Health Care Team
Nurses usually coordinate the care provided by a multidisciplinary team
The nurse is always accountable for the overall nursing care of the client.
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Delegation
Designed to make the work of client care more efficient
May delegate to an LPN or unlicensed assistive personnel (certified nurses aide, personal care assistant, nursing assistant)
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23. Factors Influencing the Delivery of Health Care
Cost
Access
Quality
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Cost
Factors contributing to the increase in cost of health care
An aging population
Technological advances
Surplus of hospital beds
Increased number of people with chronic illness
Increase in health related lawsuits
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25. Access - Limiting Factors
Inability to obtain insurance (due to high cost, pre-existing conditions, or no provision for insurance)
Cultural barriers
Shortages of health care providers (esp. in rural areas)
Limited access to services (due to lack of transportation, childcare issues)
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Quality
Estimated that 30%-40% of diagnostic/medical procedures performed in U.S. are unnecessary
Inappropriate use of resources due to:
Litigious environment that creates tendency toward defensive practice.
Resource consumption (belief that more is better)
Lack of access to and continuity of services with subsequent misuse of acute care services
Quality frequently compromised by substitution of UAP for RNs
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27. Case Studies

28. Challenges Within the Health Care System
Disillusionment with professionals
Loss of Control
Decreased Hospital Use
Changing Practice Settings
Ethical Issues
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29. Nursing’s Response to Health Care Challenges
Nursing’s Agenda for Health Care Reform
Advanced practice
Public health
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