11Fundamentals of Nursing: The Art & Science of Person Centered Care, 10th Edition; Taylor, Lynn, Bartlett. Chapter 11 Health Care Delivery System

Nursing students are reviewing information about health care delivery systems in post conference. Which statements describing current U.S. health care delivery practices should be included in the discussion? Select all that apply.

a. Access to care depends only on the ability to pay, not the availability of services.

b. The Patient Protection and Affordable Care Act provides private health care insurance to underserved populations.

c. Every health insurance plan in the Health Insurance Marketplace offers comprehensive coverage, from doctors to medications to hospital visits.

d. The uninsured pay for more than one third of their care out of pocket and are usually charged lower amounts for their care than the insured pay.

e. Fifty years ago, half of the doctors in the United States practiced primary care, but today fewer than one in three do.

f. Quality of care can be defined as the right care for the right person at t

c, e, f.

c. Every health insurance plan in the Health Insurance Marketplace offers comprehensive coverage, from doctors to medications to hospital visits.

e. Fifty years ago, half of the doctors in the United States practiced primary care, but today fewer than one in three do.

f. Quality of care can be defined as the right care for the right person at the right time.

The Health Insurance Marketplace is designed to help people more easily find health insurance that fits their budget. All plans in the Marketplace offers comprehensive coverage, from doctors to medications to hospital visits. There are many less primary care providers in the United States than there were 50 years ago. Quality is the right care for the right person at the right time. Access to care depends on both the ability to pay and the availability of services. The Patient Protection and Affordable Care Act provides Medicaid or subsidized coverage to qualifying people with incomes up to 400% of poverty. The uninsured pay for more than one third of their care out of pocket and are often charged higher amounts for their care than the insured pay.

Nurses provide care to patients in secondary health care facilities. Which patients do the nurses anticipate will receive this type of care? Select all that apply.

a. Patient seeking treatment at a community clinic for possible strep throat

b. Patient treated in the hospital following a myocardial infarction

c. Child brought to the emergency department following a seizure

d. Individual with osteogenesis imperfecta being treated in a medical center

e. Child visiting a specialist to correct a congenital heart defect

f. Patient who has a hernia repair in an ambulatory care center

b, c, f.

b. Patient treated in the hospital following a myocardial infarction

c. Child brought to the emergency department following a seizure

f. Patient who has a hernia repair in an ambulatory care center

Secondary health care treats problems that require specialized clinical expertise, such as an MI, a seizure, and a hernia repair. Treating strep throat is primary health care. Tertiary health care involves management of rare and complex disorders, such as osteogenesis imperfecta and congenital heart malformations.

A nurse working in a primary care facility prepares insurance forms in which the provider is given a fixed monetary amount per enrollee in the health plan. What term do the nurses apply to this type of reimbursement?

a. Capitation

b. Prospective payment system

c. Bundled payment

d. Rate setting

a. Capitation

Capitation plans give providers a fixed amount per enrollee in the health plan to build a payment plan that consists of the best standards of care at the lowest cost. The prospective payment system groups inpatient hospital services for Medicare patients into DRGs. With bundled payments, providers receive a fixed sum of money to provide a range of services. Rate setting means that the government could set targets or caps for spending on health care services.

A nurse working in a pediatric clinic provides codes for a patient’s services to a third-party payer who pays all or most of the care. How does the nurse refer to this method of payment?

a. Out-of-pocket payment

b. Individual private insurance

c. Employer-based group private insurance

d. Government financing

b. Individual private insurance

The four basic modes of paying for health care are out-of-pocket payment, individual private insurance, employer-based group private insurance, and government financing. The International Classification of Diseases, 10th Edition and procedure codes, or ICD-10, includes codes for new procedures and diagnoses that improve the quality of information available for quality improvement and payment purposes. With individual private insurance, members pay monthly premiums either by themselves or in combination with employer payments. These plans are called third-party payers because the insurance company pays all or most of the cost of care. Out-of-pocket payment is paying for health care with cash payments. Employer-based private insurance is employer-sponsored coverage and government financing is provided through Medicare and Medicaid, and other federally funded programs.

A nurse researcher follows current trends in health care delivery. Which present-day trends does the nurse observe? Select all that apply.

a. Globalization of the economy and society

b. Slowdown in technology development

c. Decreasing diversity

d. Increasing complexity of patient care

e. Changing demographics

f. Shortages of key health care professionals and educators

a, d, e, f.

a. Globalization of the economy and society

d. Increasing complexity of patient care

e. Changing demographics

f. Shortages of key health care professionals and educators

Trends to watch in health care delivery include globalization of the economy and society, increasing complexity of patient care, changing demographics, shortages of key health care professionals and educators, technology explosion, and increasing diversity.

A nursing student is assisting with nursing care for patients in a primary care center. Based on the setting, what activities will the student expect to perform?

a. Assisting with major surgery

b. Performing health assessments

c. Maintaining patients’ function and independence

d. Maintaining immunization records

b. Performing health assessments

Performing health assessments is a common role of the nurse in a primary care center. Assisting with major surgery is a role of the nurse in the hospital setting. Maintaining patients’ function and independence is a role of the nurse in a rehabilitation or extended-care facility, and keeping student immunization records up to date is a role of the school nurse.

The caregiver for a patient who is immobile and requires tube feedings asks the nurse to explain respite care. How does the nurse best explain this type of care?

a. “It’s a type of service that allows time away for caregivers.”

“b. It provides comfort and end-of-life services for the terminally ill and their families.”

c. “It is skilled care provided to older adults in a long-term care facility.”

“d. It provides living units available to people without regular shelter.”

a. “It’s a type of service that allows time away for caregivers.”

Respite care is provided to enable a primary caregiver time away from the day-to-day responsibilities of homebound patients.

A nurse caring for patients in a primary care setting submits paperwork for reimbursement from managed care plans for services provided. What best describes managed care?

a. System designed to control cost of care while maintaining quality

b.Care coordination to maximize positive outcomes to contain costs

c. Delivery of services from initial contact through ongoing care

d. Based on a philosophy of ensuring death in comfort and dignity

a. System designed to control cost of care while maintaining quality

Managed care is a way of providing care designed to control costs while maintaining the quality of care.

As part of a clinical paper, a nursing student interviews a hospice nurse about their role. How will the student describe the type of care the nurse provides?

a. Physical, psychological, social, and spiritual care for dying patients, their families, and loved ones

b. Preventive, primary care, focusing on diabetes education, immunizations, and prenatal care

c. Care focusing on rare diseases and specialty care

d. Care to meet the patient’s health care needs while giving a break to the patient’s caregiver

a. Physical, psychological, social, and spiritual care for dying patients, their families, and loved ones

The hospice nurse combines the skills of the home care nurse with the ability to provide daily emotional support to dying patients and their families. Respite care caregivers of homebound ill, disabled, or older adults. Palliative care, which can be used in conjunction with medical treatment and in all types of health care settings, is focused on the relief of physical, mental, and spiritual distress. Extended-care facilities include transitional subacute care, assisted-living facilities, intermediate and long-term care, homes for medically fragile children, retirement centers, and residential institutions for mentally and developmentally or physically disabled patients of all ages.

Nursing students learn advance practice nurses can write medication prescriptions. Which roles may be performed by an advanced practice registered nurse? Select all that apply.

a. Primary care provider

b. Hospitalist

c. Physical therapist

d. Anesthetist

e. Midwife

f. Pharmacist

a, d, e.

a. Primary care provider

d. Anesthetist

e. Midwife

The Advanced Practice Registered Nurse (APRN) is a registered nurse educated at the master’s or post-master’s level in a specific role and for a specific population. Whether they are nurse practitioners, clinical nurse specialists, nurse anesthetists, or nurse midwives, APRNs play a pivotal role in the future of health care. APRNs are often primary care providers and are at the forefront of providing preventive care to the public. Hospitalists are health care providers who provide care to patients when they visit the emergency department or are admitted to the hospital. A physical therapist completes a specific training program to learn to help patients restore function or to prevent further disability in a patient after an injury or illness. A pharmacist, prepared at the doctoral level, is licensed to formulate and dispense medications.

The nurses at a large community hospital with several campuses are members of a committee working toward obtaining Magnet status. What activity will best meet their goal?

a. Recruiting excellent surgeons and medical doctors

b. Offering health prevention activities in the community

c. Providing high-quality patient care, using innovative practices

d. Seeking culturally diverse clergy to meet patient’s spiritual concerns

c. Providing high-quality patient care, using innovative practices

Magnet hospitals meet strict requirements and standards representing the highest quality of professional nursing practice and patient care, nursing excellence, and innovations in practice. Physicians are recruited by the medical department, health prevention activities in the community could be conducted by nursing staff but are not required activities; chaplains, nurses, and others may provide spiritual care, but it is not the focus of a Magnet designation

During a meeting with nurses at all levels in an acute care hospital, the Director of Nursing discusses lost revenue due to Medicare penalties. The nurses plan improvements in practice designed to prevent penalties from which events? Select all that apply.

a. Urinary catheter–related infections

b. Blood infections from central venous catheters

c. Excessive readmissions

d. Pressure injuries

e. High blood pressure

a, b, c, d.

a. Urinary catheter–related infections

b. Blood infections from central venous catheters

c. Excessive readmissions

d. Pressure injuries

Medicare penalties are given to hospitals when patients are readmitted soon after discharge; this is designed to ensure patients receive needed coordinated care after discharge. In addition, Medicare no longer reimburses hospitals for conditions that result from preventable errors and lead to increased costs. These include pressure injuries, injuries caused by falls, infections associated with indwelling urinary catheters, vascular catheter–associated infections, infections of the mediastinum after coronary artery bypass graft, air embolisms, adverse reactions to incompatible blood infusions, and retained sponges or instruments during surgery.

Nursing students are asked to provide interprofessional care during their clinical experience. Which member of the health care team will the student contact for an uninsured patient?

a. Nurse practitioner

b. Admissions coordinator

c. Social worker

d. Hospital chaplain

c. Social worker

Social workers assist patients and families in dealing with the social, emotional, and environmental factors that affect their well-being. They make referrals to appropriate community resources, participate in discharge planning to obtain equipment and supplies, and assist with health care finances. Nurse practitioners assist in managing the medical and nursing needs of a patient, the admissions coordinator performs administrative intakes and may assign beds, and the hospital chaplain attends to patients’ spiritual needs.