Health Care System Lecture NURN 129 Exam 1

What is the U.S. health care delivery system, and what are its major goals?

A network of health care professionals, organizations, resources, and payment systems. Its goals are access, safety, effectiveness, positive patient experiences, equity, and responsible use of health care costs.

What is the difference between primary, secondary, and tertiary health care?

Primary: First-contact, comprehensive, ongoing care. Secondary: Specialized consultation and treatment. Tertiary: Highly specialized, complex treatment. Examples: Family doctor = primary; cardiologist consultation = secondary; organ transplant center = tertiary.

A patient sees a family physician for hypertension, is referred to a cardiologist, and later receives an organ transplant. Identify each level of care.

Family physician = primary. Cardiologist = secondary. Organ transplant center = tertiary. The complexity and specialization of care increase across the three levels.

What is the nurse's role in primary health care?

Support ongoing patient care through assessment, education, coordination, advocacy, and recognition of health needs. Example: Educating a patient with hypertension about their treatment plan and follow-up.

What is the nurse's role in secondary health care?

Coordinate and educate during specialized consultation or treatment. Example: Preparing a patient for a cardiology visit and communicating relevant assessment findings.

What is the nurse's role in tertiary health care?

Participate in coordinated care for complex health conditions involving multiple specialists. Example: Monitoring, educating, and coordinating care for a patient receiving highly specialized treatment.

Where can nurses work within the health care delivery system?

Acute care, ambulatory care, long-term care, rehabilitation, home health, hospice, community/public health, school nursing, case management, and higher education.

What are the responsibilities of the RN, provider, pharmacist, PT/OT, and respiratory therapist?

RN: Assessment, education, coordination, advocacy. Provider: Diagnosis and treatment planning. Pharmacist: Medication expertise. PT/OT: Mobility and daily functioning. Respiratory therapist: Breathing therapies.

A patient cannot afford prescribed medications and has no transportation to follow-up appointments. Which team member should the nurse collaborate with?

Social work or case management. These professionals help connect patients with resources and coordinate safe transitions between care settings. The RN identifies barriers and collaborates rather than ignoring them.

What is SBAR, and how does the nurse use it when communicating with other providers?

S — Situation: What is happening now? B — Background: What relevant information explains the situation? A — Assessment: What did the nurse observe? R — Recommendation: What does the nurse need or recommend? It organizes communication between health care professionals.

A patient is being discharged with three new medications, oxygen, and a follow-up appointment. What problems should the nurse anticipate?

Medication misunderstanding, inability to obtain medications, difficulty using oxygen, transportation barriers, and missed follow-up care. These can disrupt the transition from hospital to home.

A patient cannot explain their new medication schedule before discharge. What should the nurse do?

Provide understandable education, use teach-back, identify barriers, and coordinate necessary support. Do not assume discharge teaching was successful simply because information was provided.

What are the major ways Americans obtain or pay for health care?

Private insurance (employer-sponsored or individual), Medicare, Medicaid, CHIP, TRICARE/VA programs for eligible populations, and self-pay.

What is the difference between private insurance and self-pay?

Private insurance involves coverage through an employer-sponsored or individually purchased plan. Self-pay means the patient pays directly for health care services.

What is the difference between Medicare and Medicaid?

Medicare: Primarily covers adults age 65 and older and eligible younger individuals. Medicaid: A joint federal-state program based on income and other eligibility requirements. NCLEX clue: Age 65+ suggests Medicare; financial eligibility suggests Medicaid. Some people qualify for both.

What are CHIP, TRICARE, and VA health care programs?

CHIP: Coverage for eligible children who do not qualify for Medicaid but whose families cannot afford other coverage. TRICARE/VA: Health care or coverage programs serving eligible military-connected populations.

What is the difference between a premium and a deductible?

Premium: Recurring payment to maintain insurance coverage. Deductible: Amount the patient pays for covered services before many insurance benefits apply. Example: Monthly insurance bill = premium. Required out-of-pocket spending before coverage begins paying for many services = deductible.

What is the difference between a copayment and coinsurance?

Copayment: Fixed amount paid for a covered service. Coinsurance: Percentage of covered costs paid by the patient. Example: A fixed $25 visit charge = copay. Paying 20% of covered costs = coinsurance.

What does an insurance network mean, and how can it affect access to health care?

A network consists of clinicians and facilities contracted with an insurance plan. Network restrictions may influence which providers patients can access and their costs.

A patient has health insurance but cannot afford a $75 medication copay. What should the nurse do FIRST?

Explore financial barriers and collaborate on available options. Do not: Tell the patient to skip doses, insist they pay, or simply document the problem without investigating. NCLEX principle: Having insurance does not guarantee that a patient can afford care.

What factors can prevent patients from accessing health care even when they have insurance?

Medication costs, copays, limited provider access, transportation difficulties, and other social determinants of health. Coverage alone does not eliminate barriers.

What are social determinants of health (SDOH)?

Nonmedical conditions in which people are born, grow, live, learn, work, and age that influence health, well-being, and quality of life. Examples: Income, education, housing, transportation, and social support.

What are the five major domains of social determinants of health?

Economic Stability: Employment, income, food and housing security. Education Access and Quality: Literacy, education, learning opportunities. Health Care Access and Quality: Insurance, providers, quality of services. Neighborhood and Built Environment: Housing conditions, transportation, environmental safety. Social and Community Context: Support, discrimination, relationships, inclusion.

A patient cannot afford nutritious food, cannot understand medication instructions, and has no transportation. Which SDOH domains are involved?

Food insecurity = economic stability. Difficulty understanding instructions may involve education access and quality. Transportation difficulty = neighborhood and built environment. Multiple domains can contribute to one patient's barriers.

What does health equity mean, and how should nurses apply it?

Health equity involves responding to different patient needs and barriers so people have fair opportunities for good health. Example: A patient who cannot understand written instructions may require a different teaching approach rather than simply receiving the same handout as everyone else.

What are the three primary goals of the Affordable Care Act (ACA)?

Expand access to affordable health insurance. Expand Medicaid eligibility, with state participation varying. Support innovative health care delivery approaches intended to reduce overall costs. The ACA also includes financial assistance through premium tax credits for qualifying households. HHS.gov

What strategies can help reduce health care costs while maintaining quality?

Improve efficiency, avoid unnecessary waste, reduce harmful delays, coordinate transitions, and address preventable barriers to care. The ACA also supports innovation aimed at reducing costs. Application: Improving discharge education and resolving medication and transportation barriers may help reduce avoidable readmissions.

What are the six dimensions of quality health care?

Safe: Prevent harm. Effective: Use evidence. Patient-centered: Honor patient values and preferences. Timely: Reduce harmful delays. Efficient: Avoid waste. Equitable: Address unjust differences.

What is the difference between safe and effective care?

Safe care: Prevents patient harm. Effective care: Uses evidence to guide treatment. Example: Checking patient identifiers promotes safety; using an evidence-supported intervention promotes effectiveness.

What is the difference between timely and efficient care?

Timely: Preventing harmful delays in providing care. Efficient: Avoiding unnecessary waste of resources. Example: Addressing recurring treatment delays supports timely care, while eliminating unnecessary duplication supports efficient care.

What is the difference between patient-centered and equitable care?

Patient-centered: Respects individual goals, values, concerns, and informed decisions. Equitable: Recognizes and addresses unfair barriers between patients or populations. Example: Respecting a patient's informed refusal is patient-centered. Addressing language barriers is equitable and can also support patient-centered care.

What is the role of CMS versus The Joint Commission?

CMS (Centers for Medicare & Medicaid Services): Oversees coverage programs and quality-related requirements. The Joint Commission: Accredits health care organizations and establishes safety expectations. NCLEX clue: Accreditation = Joint Commission. Medicare/Medicaid program administration = CMS.

What is the difference between AHRQ and CDC?

AHRQ (Agency for Healthcare Research and Quality): Develops research and tools supporting health care quality and patient safety. CDC (Centers for Disease Control and Prevention): Provides infection prevention and public health guidance. Application: Infection prevention concerns relate to CDC guidance; health care quality research and improvement tools relate to AHRQ.

What is the difference between NCSBN and the State Board of Nursing?

NCSBN (National Council of State Boards of Nursing): Supports nursing regulation and the NCLEX. State Board of Nursing: Responsible for licensure and scope of practice within its state. NCLEX clue: State-specific nursing licensure and scope = State Board of Nursing.

What are the six QSEN nursing competencies?

Patient-centered care Teamwork and collaboration Evidence-based practice Quality improvement Safety Informatics QSEN focuses on the knowledge, skills, and attitudes necessary to improve health care quality and safety. QSEN

A patient refuses a recommended treatment after the nurse explains it. What response demonstrates patient-centered care?

Explore the patient's concerns, respect their informed decision, and notify the provider as appropriate. Do not: Force treatment, ask family members to override the patient's decision, or document the refusal without further assessment.

A patient speaks a different language and cannot explain their discharge instructions. Which patient-centered nursing actions are appropriate?

Use an appropriate interpreter, explain information in understandable language, and use teach-back to evaluate understanding. Respect the patient's preferences and support informed decisions.

What is the difference between evidence-based practice (EBP) and quality improvement (QI)?

EBP: Uses the best available evidence to guide care. QI: Examines care processes and outcomes to improve quality. Scenario: A nurse uses research to guide treatment = EBP. A team reviews recurring medication delays to improve workflow = QI.

What is the difference between the QSEN competencies of safety and informatics?

Safety: Preventing harm to patients. Informatics: Using information and technology to support communication, knowledge, and clinical decisions. Example: Checking two patient identifiers = safety. Reviewing and documenting information in the EHR = informatics. One action may involve multiple competencies.

A nurse identifies repeated delays in antibiotic administration, documents the problem, and joins a team to review the pattern. Which QSEN competencies are demonstrated?

Primarily quality improvement, because the team is analyzing recurring delays to improve care. Teamwork and collaboration are also involved. If electronic data are analyzed, informatics may contribute. NCLEX rule: When the question asks for the most directly demonstrated competency, choose the primary purpose of the action.

What does it mean to be a professional nurse in contemporary health care?

A professional nurse provides safe, evidence-informed, patient-centered care; works collaboratively; communicates effectively; advocates for patients; and contributes to improvements in health care quality and equity. This answer synthesizes responsibilities described across your provided sources.

How can nurses enhance the public image of the nursing profession?

Demonstrate competence, compassionate care, effective communication, patient advocacy, teamwork, leadership, and commitment to quality and safety. Application: Nurses demonstrate their professional role by assessing patient needs, coordinating care, educating patients, and participating in health care improvement.

A patient cannot afford medication and has no transportation for follow-up. How does the nurse advocate for the patient?

Recognize and communicate the barriers, collaborate with social work/case management, and help identify accessible care options. Do not: Assume the patient is noncompliant or ignore barriers because the patient has insurance.

What does advocacy for oneself as a nurse involve?

Recognizing professional needs, communicating concerns, seeking appropriate resources and support, and contributing to a safe, healthy working environment. Application: A nurse identifying an unsafe recurring care-process problem should communicate the concern and participate in improving the process.

How can nurses advocate for the nursing profession and health equity?

Participate in leadership, collaborate across professions, advocate for underserved populations, support equitable care, and contribute nursing expertise to improvements in health systems and policies. The Future of Nursing report emphasizes nurses' roles as leaders and advocates for health equity. NCBI Bookshelf

What major trends in nursing education are identified in the Future of Nursing report?

Greater emphasis on health equity, SDOH, community-based learning, interprofessional collaboration, diverse nursing education, telehealth, and digital health skills. The report also discusses AACN Essentials as a framework outlining expected competencies across nursing education levels. NCBI Bookshelf

Why are nursing research and evidence-based practice important to professional nursing?

Research contributes evidence that nurses can use to improve care. Evidence-based practice helps nurses make informed decisions, while quality improvement examines ways to improve existing care processes and outcomes. Example: Applying evidence to a clinical intervention = EBP. Studying repeated treatment delays to improve workflow = QI.

Why is lifelong learning important for professional nurses?

Nurses need to continue developing knowledge and skills as patient needs, health care technologies, evidence, and health systems evolve. Application: Continuing education can help nurses strengthen skills in patient safety, health equity, new technology, and collaboration. QSEN identifies competencies relevant to pre-licensure preparation, transition to practice, and continuing education. QSEN

How can reflective writing support nursing professionalism?

Reflective writing helps a nurse examine experiences, identify strengths and improvement opportunities, and establish goals for future practice. Application: After a challenging discharge, a nurse can reflect on what happened, what communication could improve, and how to support a safer transition next time. This is an application of your study-guide objective, rather than a specific reflective-writing model defined in the supplied sources.

What should a preliminary professional nursing career-development plan include?

A nursing career goal, the preparation and competencies needed, opportunities for clinical and professional learning, and a plan for continuing development. Example: Establish a goal of becoming a safe, competent RN; strengthen assessment, communication, patient-centered care, and teamwork; then pursue further education and professional growth consistent with future career goals.