1. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 3 The Healthcare Delivery System

2. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Healthcare Trends and Challenges in the 21 st Century There is an emphasis on wellness and individuals assuming more responsibility for their own health. Technology continues to influence healthcare. The rising costs of healthcare are to be met by preventive care. Health education is an important aspect of healthcare. Health maintenance organizations (HMOs) provide managed care; they emphasize disease prevention and health promotion.

3. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins The Impact of the Changes on Nurses, Healthcare Practitioners, and Clients Healthcare may involve discussion among the healthcare practitioner, an insurance provider, and the client. With the increasing challenges, it is not uncommon for unlicensed assistive personnel (UAPs) to be hired to administer nursing care. As a result of financial constraints and the influence of managed care plans, clients may even be forced to have treatment outside a hospital.

4. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins The Impact of the Changes on Nurses, Healthcare Practitioners, and Clients As a result of specific changes in the delivery of healthcare services, extended care facilities (ECFs) and home healthcare services have restructured to meet the intermediate acuity needs of clients. For example, a client may be discharged from an acute care hospital to be admitted into an extended care facility to received physical therapy and rehabilitation before being discharged to home.

5. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Acute Care and Extended Care Facilities Acute Care FacilitiesExtended Care Facilities Clients with serious conditions or high level of acuity are admitted for a short period. Clients discharged from acute care facilities may be admitted for a longer period. Include: Acute care hospitals Intensive care units Subacute care facilities Include: Skilled nursing facilities Intermediate care facilities Inpatient rehabilitation centers

6. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Outpatient Care Centers Most general hospital provide “same day” surgery, also known as outpatient or ambulatory care centers.

7. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Specialized Hospitals –These facilities admit only one type of client for specific conditions. Home Healthcare –Service provided by an acute care facility or an agency that specializes in home healthcare. Hospice –Specializes in the care of the terminally ill Healthcare Settings and Services

8. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Respite Care –Part-time supervision of clients who have chronic conditions Telehealth –Ability to access a nurse or physician via telephone or computer audio/video link Healthcare Settings and Services (cont’d)

9. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? Extended care facilities include intensive care units for the critically ill.

10. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False Clients who are admitted to the intensive care unit meet the minimal level or need for healthcare services known as acuity and are thus admitted to acute care facilities, not extended care facilities.

11. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Community Health Services Public health service –Immunizations, well-baby checks, and treatment for specific diseases Community health clinics –Low-cost healthcare services to the public Independent living facilities –Stable, home-like environment for mentally challenged individuals

12. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins School Nurse Cares for ill children Provides intensive nursing care for the physically challenged Promotes preventive care by regular assessments, teaching, and screening for common disorders Supervises administration of immunizations and medications Provides teaching and health counseling

13. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Industrial Nurse Promotes health Teaches prevention of accidents Serves as a liaison between the industry and the Occupational Safety and Health Administration (OSHA)

14. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Functions of The Joint Commission The Joint Commission accredits a hospital or other healthcare facility. It has established rigid standards for an ongoing quality assurance program in acute care and extended care facilities. It requires objective and systematic monitoring and evaluation of the quality and appropriateness of client care.

15. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Relation of The Joint Commission’s Functions to Nursing The Joint Commission stresses the importance of quality assurance. As a result, facilities and agencies have contiguous quality improvement (CQI) committees that monitor the quality of ongoing care. The process of care relates to how care is given. The outcome, which is equally important, relates to the result, which is also known as outcome-based care. Thus, nurse accountability, which involves the delivery and accurate documentation of quality care, is vital.

16. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Quality Assurance in Healthcare Facilities Quality assurance focus on delivery of care. The standards of quality include: –Standards of nursing practice –Standards of client/patient care –Standards of performance The nursing audit committee or CQI committee evaluates care given to clients. Peer review allows nurses to constructively critique each other.

17. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Roles of the Client Representative and Advocate or Ombudsperson To act as a consumer advocate and assist the client and family by resolving concerns or problems To focus on client care, needs, and concerns, and listen and answer questions To help clients and their families find needed services like housing, child care, etc During hospitalization, clients have the right to contact their representatives if they have a concern. Each individual receives a copy of the Patient’s Bill of Rights. The nursing case manager has overall responsibility for the client’s care, and the advocate assists as needed.

18. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? A client representative can also be called a consumer advocate.

19. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True Client representatives act as consumer advocates and assist the client and family by resolving concerns or problems.

20. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Hospital Organization and Ownership Numerous trained individuals work together in organized units Government ownership Private ownership –Proprietary, investor-owned, or for-profit –Not-for-profit

21. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Financing Healthcare The Health Planning and Resources Development Act of 1975 established legislation to govern the amount and types of facilities, services, and workers needed in each designated geographic area in the United States. Resources for the 21st century must include at least 24 healthcare priorities.

22. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Methods of Payment Individual Private Insurance: private health insurance. Group Insurance: companies, institutions, fraternal organizations. Fee for Service Plans: medical bills, hospitalization, surgery, laboratory. Health Maintenance Organizations (HMOs): fixed monthly charge called premium. Preferred Provider Organizations (PPOs): deliver healthcare within a “managed” system.

23. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Methods of Payment (cont’d) Point of Service Plans (POS): similar to HMO and PPO they are all types of managed care. Medicare: federal health insurance (people 65 years of age, disabilities younger 65) Part A- covered hospital, nursing facilities, hospice ect. Part B- physician services, outpatient hospitals and medications. Medicaid: is the United States health program for certain people and families with low incomes and resources. It is a means-tested program that is jointly funded by the state and federal governments, and is managed by the states. Prospective Payment: is a reimbursement system in which determinate amount of is allocated for treating individuals with specific diagnoses. If this reimbursement occurred years past,then is called: retrospective payment.

24. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Cont’d Diagnosis-Related Groups (DRGs): Prospective Payment is based in DRGs, for hospital and home care, the original objective of diagnosis related groups (DRG) was to develop a classification system that identified the "products" that the patient received. Since the introduction of DRGs in the early 1980s, the healthcare industry has evolved and developed an increased demand for a patient classification system that can serve its original objective at a higher level of sophistication and precision. To meet those evolving needs, the objective of the DRG system had to expand in scope. Today, there are several different DRG systems that have been developed in the US. Some hospitals and home care had to adjusted their expensives in order to survive.

25. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following is not a feature of HMOs? a. Each plan has a predetermined co-pay. b. Members can use any physician they choose, and the HMO will pay for this service. c. A premium must be paid in advance to the HMO. d. Members prepay for healthcare services generally through payroll deductions, etc. e. Most HMOs include group practice, prepayment, prevention, and treatment.

26. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer b. Members can use any physician they choose, and the HMO will pay for this service. Members must use a physician within the HMO network. HMO members can elect to go to any physician or seek any medical service that is not part of the HMO network. However, the HMO will generally not pay for this service unless it is preapproved by the administrators of the plan.

27. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Complementary Healthcare Chiropractic, Physical, and Occupational Therapy Holistic Healthcare Herbalists and Vibrational Remedies Acupuncture and Acupressure Relaxation and Imagery Meditation Therapeutic Touch

28. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Consumer Fraud As a result of misleading the public with “sure cures,” ill people run the risk of delaying vital treatment for diseases such as cancer and obesity until it is too late. The general public often cannot tell the difference between true and false claims. As a nurse, you may encourage clients to find out all the facts before starting any untested healthcare measure.

29. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins End of Presentation