Chapter 8 Healthcare Delivery Systems

Frameworks for Healthcare Delivery Managed care systems Case management Primary healthcare

Question In which healthcare delivery framework is the primary care provider referred to as the “gatekeeper” assigned to provide care that controls the cost while maintaining the quality of that care? A. Managed care B. Case management C. Primary healthcare D. Federally funded healthcare

Answer Answer: A. Managed care Rationale: Managed care systems provide care that controls the cost while maintaining the quality of care. Case management is a method of managed care in which nurses often identify protocols and timetables for care. Primary healthcare is essential healthcare accessible to communities at a cost that is affordable. Federally funded healthcare programs include Medicare and Medicaid.

Managed Care Systems Controls cost of care while maintaining quality of care Manager or “gatekeeper” plans and monitors the care Limits the choice of care providers Requires approval for specialty care

Case Management Coordinates care Role of nurse is coordinator of care Controls costs Improves access to healthcare Uses critical pathways to identify protocols and timetables for care

Primary Healthcare Essential healthcare based on acceptable methods and technology Universally accessible and affordable to individuals and families in the community Brings healthcare close to where people live and work

Healthcare Settings Hospitals Primary care centers Ambulatory care centers and clinics Home healthcare Long-term care facilities Specialized care centers and settings Healthcare services for caregivers and end-of-life care Healthcare agencies

Question Tell whether the following statement is true or false. An urgent care center is a type of ambulatory care center that provides walk-in emergency care services. A. True B. False

Answer Answer: A. True An urgent care center is a type of ambulatory care center that provides walk-in emergency care services.

Hospital Settings Provide inpatient and outpatient care Vary in size and services Classified as profit or nonprofit, public or private Employ more nurses than any other facility

Role of Nurses in Hospitals Direct care providers Manager of other members of healthcare team Administrator Nurse practitioner Clinical nurse specialist Patient educator In-service educator Researcher

Role of Nurse in Primary Care Centers Make health assessments. Perform technical procedures. Assist the physician. Provide health education.

Role of Nurse in Ambulatory Care Centers Provide technical services. Determine the priority of care needs. Provide teaching about all aspects of care.

Long-Term Care Facilities Transitional subacute care Intermediate and long-term care Nursing homes Retirement centers Residential institutions for mentally or physically disabled “Aging in place”

Specialized Care Centers Daycare centers Mental health centers Rural health centers Schools Industry Homeless shelters Rehabilitation centers

Question Which of the following is designed to provide palliative and supportive care services for dying persons? A. Respite care B. Parish nursing C. Voluntary agencies D. Hospice services

Answer Answer: D. Hospice services Rationale: Hospice provides physical, psychological, social, and spiritual care for dying persons. Respite care is provided for caregivers of homebound ill, disabled, or elderly patients. Parish nursing emphasizes holistic care, health promotion, and disease prevention activities. Voluntary agencies are community agencies that are often nonprofit and provide a setting for support groups.

Home Healthcare Most rapidly growing area of the healthcare system Driven by payment system of reimbursement—early discharge from hospitals Serves increasing number of older people with chronic illnesses Provides for a dignified death at home

Healthcare Agencies Voluntary agencies Parish nursing Government agencies Veterans administration and military agencies Public health service Public health agencies

Members of the Healthcare Team Physician, physician assistant Physical, respiratory, occupational, and speech therapist Dietitian Pharmacist Social worker Unlicensed assistive personnel

Role of the Physician Diagnosis of illness Medical or surgical treatment of illness Prescribing medications Interpreting results of lab and diagnostic tests Performing procedures and surgery

Payment for Healthcare Federally funded programs Medicare—DRGs Medicaid Group plans Health maintenance organizations Preferred provider organizations Private insurance Long-term care insurance

Question In which of the following healthcare payment plans does the patient have the least control of the choice of a physician for his or her care? A. Preferred provider organizations B. Private insurance C. Health maintenance organizations D. Federally funded healthcare programs

Answer Answer: C. Health maintenance organizations Rationale: HMOs are prepaid group-managed care providers that subscribe to receive care through affiliated providers. Preferred provider organizations allow members to choose an outside physician for an additional cost. Private insurance allow members to choose their own physicians. Federally funded healthcare programs use a prospective payment plan based on diagnosis-related groups.

Healthcare Delivery Trends Changing demographics Increasing diversity Technology explosion Globalization of economy and society Educated consumers Increasing complexity of patient care Costs of healthcare Effect of health policy and regulation Current nursing shortage

Healthcare Issues Focus on preventive care Knowledgeable consumers Cost containment Fragmentation of care Healthcare—a right or a privilege?

Goals of Healthcare Reform Cost containment Improved access to care Increased quality of services for all

Nurse’s Role in Healthcare Reform Stay informed about current issues and legislation. Write members of congress to support legislation to improve nursing care. Belong to nursing organizations. Document the outcomes of nursing care. Be a leader in nursing and consumer groups. Advocate for the right of all to healthcare.