1. Basic Nursing: Foundations of Skills & Concepts Chapter 5
THE HEALTH CARE DELIVERY SYSTEM

2. What is the Health Care Delivery System?
A mechanism for providing services that meet the health-related needs of individuals.

3. Three levels of Health Care
Primary
Secondary
Tertiary

4. Primary Care
Goal: To decrease the risk to a client (individual or community) of disease or dysfunction.
Approach: General health promotion. Protection against specific illnesses.

5. Secondary Care
Goal: To alleviate disease and prevent further disability.
Approach: Early detection and intervention.

6. Tertiary Care
Goal: To minimize disability associated with chronic or irreversible conditions.
Approach: Restorative and rehabilitative activities to attain optimal level of functioning.

7. The U.S. System
Health care services are delivered and financed by three sectors:
The public (official, voluntary, and nonprofit agencies)
Public/private
Private (hospitals, extended-care facilities, hospices, schools, etc.)

8. Health Care Settings Hospital Extended-care facilities
Home health care agencies
Hospices
Out-patient settings
Schools
Industrial Clinics
Managed care organizations
Community nursing centers
Rural primary care hospitals

9. Health Care Team Members
Health care is delivered by a multidisciplinary team, all working together. Examples include:
Physician (MD)
Nurse (RN, LP/VN)
Nurse Assistant (CAN)
Registered Dietician (RD)

10. Economics of Health Care
The U.S. health care system has a diverse base:
32% private insurance
14.8% medicaid
18.8% Medicare
11.8% Other public programs
17.4% Out of Pocket
4.5% Other private

11. Private Insurance Model
Basis of U.S. system
Individual pays monthly premiums for coverage and receives access on an as needed basis

12. Managed Care Model
Developed to provide coordinated care with an emphasis on prevention
A system of providing and monitoring care wherein access, cost, and quality are controlled before or during delivery of service

13. HMOs, PPOs and EPOs
Health Maintenance Organizations (HMOs) have a single point of entry. Entry into the health plan through a point designated by the plan.
Preferred Provider Organizations (PPOs) allow individuals to access health care from within a pool of providers.
Exclusive Provider Organizations (EPOs) are similar to PPOs except that care is intended to be delivered exclusively from within the selected pool of providers.

14. Federal Insurance Plans
Medicare: Provides health care coverage for elderly persons and disabled persons.
Medicaid: Federal and Local administered program that provides health care services for the poor.

15. Factors Influencing Health Care
Cost
Access
Quality

16. Cost Issues Many factors influence costs:
An oversupply of specialized providers
A surplus of hospital beds
The passive role assumed by most consumers.
The aging of the population.
The increased number of people with chronic illnesses.
Unnecessary use of services (e.g. additional diagnostic testing) and increase in health-related lawsuits.

17. Access Issues
Many factors influence an individuals ability to access the health care system:
Inadequate or cost of insurance
Cultural barriers
Limited access to ancillary services (e.g. child care, transportation)
Certain preexisting conditions making it difficult to obtain insurance
Shortage of providers in rural or inner city areas

18. Quality Issues
Many factors influence the quality of care individuals receive:
The litigious environment and response toward defensive practice (e.g. ordering all possible tests).
The widely held American belief that more is better.
Lack of access to and continuity of services result in subsequent misuse of acute services.

19. Challenges The U.S. Healthcare system faces some serious challenges:
Public’s disillusionment with providers
Public’s loss of control over health care decisions
Changes in practice settings
Decreased use of hospitals and related impact on quality of care
Ethical issues
Health care needs of vulnerable populations

20. Nursing’s Response to the Challenges
The nursing profession has responded to the multiple challenges in health care delivery by proposing a plan for reform.

21. Nursing’s Vision for the Future
To provide health care services that emphasize PREVENTION and PRIMARY HEALTH CARE for clients, thereby helping to reduce costs and increase the quality of health care