Chapter 11: Health Care Delivery System
IOM Outcomes for Health Care in the 21st Century
- The Institute of Medicine (IOM) identified six critical outcomes for a new health care system to achieve in the 21st Century:
* Safe: Avoiding injuries to patients from the care that is intended to help them.
* Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse, respectively).
* Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy.
* Patient-centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.
* Timely: Reducing waits and sometimes harmful delays for both those who receive and those who give care.
* Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.
Big-Picture Issues in Health Care
- There are three primary thematic issues facing the health care delivery system:
* Access to health care.
* Quality and safety of health care.
* Affordability of health care.
Access to Health Care and the PPACA
- Patient Protection and Affordable Care Act (PPACA): This legislation addresses systematic barriers to obtaining care.
- Health Insurance Marketplace: A new mechanism established for individuals to find health insurance that aligns with their specific budget.
- Factors complicating access include:
* Shortage of providers.
* Specific legislation addressing health care access limitations.
* Caring for persons who are undocumented in the United States.
- Goals of the PPACA:
* To expand insurance coverage.
* To control health care costs.
* To improve the general health care delivery system.
- Medicaid and Subsidies: The PPACA provides Medicaid or subsidized coverage to qualifying people with incomes up to 400% of the poverty level, a provision that began in 2014.
Quality and Safety Mechanisms
- Reliable Care Accountability Matrix: A framework used to ensure consistency in care delivery.
- Pay for Performance/Value-Based Purchasing: Financial models that reward health care providers for meeting specific performance measures for quality and efficiency.
- Penalties for Excess Readmissions: Financial consequences for hospitals that have high rates of patients returning for the same issue shortly after discharge, incentivizing better initial care and follow-up.
Affordability and Financial Models
- Systems of Payment:
* Multi-payer System: A system where multiple private and public entities pay for health care services.
* Single-payer System: A system where one entity (usually the government) pays for all health care costs.
- Methods for Controlling and Managing Costs:
* Diagnosis-Related Groups (DRGs): A system to classify hospital cases into groups that are expected to have similar hospital resource utilization.
* Resource Utilization Groups (RUGs): A system used primarily in long-term care to determine reimbursement rates based on the needs of the resident.
* Bundled Payments: A single payment for all the services provided for a single stay or episode of care.
* Rate Setting: Regulations that determine the prices charged for services.
* Comparative Effectiveness Analysis: Studying which treatments work best for which patients.
* Increasing Patient Cost Sharing: Requiring the patient to pay a higher portion of their medical costs (e.g., higher deductibles or co-pays).
Levels of Health Care Delivery
- Primary Health Care: Focuses on the treatment of common health problems and preventative measures.
- Secondary Health Care: Involves the treatment of clinical problems that require more specialized expertise or specialized equipment.
- Tertiary Health Care: Revolves around the management of rare and highly complex health disorders.
Health Care Delivery Systems and Care Coordination
- Organizational Structures:
* Providers and Hospitals.
* Multispecialty Group Practices: Groups of doctors from various specialties working together.
* Community Health Centers.
* Prepaid Group Practices: Including Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs).
* Accountable Care Organizations (ACOs).
* Medical Homes and Medical Neighborhoods: Models designed to centralize and coordinate patient care.
- Care Coordination: The deliberate organization of patient care activities to facilitate the effective delivery of health care services.
Paying for Health Care
- Out-of-pocket Payment: Patients pay directly for services.
- Individual Private Insurance: Policies purchased by individuals.
- Employer-based Private Insurance: Policies provided as part of an employment package.
- Government Financing:
* Medicare: Federally funded health insurance for the elderly and disabled; utilizes DRGs.
* Medicaid: State and federally funded program for individuals with low income.
* Children’s Health Insurance Program (CHIP): Provides coverage for children in families that earn too much for Medicaid but cannot afford private insurance.
* Veteran’s Health Administration (VHA): Comprehensive health system for veterans.
Strategies for Cost Reduction and Efficiency
- Utilizing quality improvement tools to minimize waste and enhance patient safety.
- Improving transitions of care across different clinical settings.
- Enhancing the efficiency of medical service delivery to lower costs.
- Eliminating unnecessary costs, specifically targeting fraud and abuse.
- Focusing on improving population health metrics.
Health Care Settings
- Hospitals: Provide acute care and specialized services.
- Primary Care Centers: Routine checkups and common illness treatment.
- Ambulatory Care Centers and Clinics: Outpatient services.
- Home Health Care: Care provided in the patient's residence.
- Extended Care Services: Subacute, long-term, or transitional care.
- Specialized Care Centers: Daycare, mental health, rural centers, schools, industry, homeless shelters, and rehabilitation centers.
- Seriously Ill and Dying Services: Respite care (for caregivers), Hospice, and Palliative care.
Roles of the Nurse in Health Care
- Hospital Roles:
* Direct care provider.
* Manager of other health care team members.
* Administrator.
* Nurse Practitioner (NP).
* Clinical Nurse Specialist (CNS).
* Patient Educator.
* In-service Educator.
* Researcher.
- Primary Care Roles:
* Advanced Practice Registered Nurses (APRNs), NPs, Midwives, and CNSs work independently or collaboratively with physicians.
* They perform assessments and care for patients needing health maintenance or promotion.
* Depending on state regulations, APRNs may operate their own clinics and refer only complex cases to physicians.
- Home Health Care Roles:
* Provided via community health departments, visiting nurses’ associations, or hospital-based managers.
* Driven by early hospital discharge payment systems.
* Services include skilled nursing assessment, medication administration, teaching, family support, and direct care.
- Specialty Roles:
* Parish Nursing: Emphasizes holistic care, health promotion, and disease prevention activities.
Extended Care and Specialized Facilities
- Types of Facilities:
* Transitional subacute care.
* Assisted-living facilities.
* Intermediate and long-term care.
* Homes for medically fragile children.
* Retirement centers.
* Residential institutions for the mentally or physically disabled.
* Senior retirement communities.
- "Aging in place": A concept focusing on keeping seniors in their homes or communities as they age.
Questions & Discussion
- Question 1: Tell whether the following statement is true or false: The role of the nurse in hospitals includes managing other members of the health care team.
* Answer: True.
* Rationale: Nurses in hospitals provide direct patient care, educate patients, conduct research, and manage other members of the health care team.
- Question 2: Which of the following is designed to provide palliative and supportive care services for dying persons?
* Options: A. Respite care; B. Parish nursing; C. Voluntary agencies; D. Hospice services.
* Answer: D. Hospice services.
* Rationale: Hospice provides physical, psychological, social, and spiritual care for the dying. Respite care is for caregivers. Parish nursing is holistic and preventative. Voluntary agencies are often nonprofit support groups.
Collaborative Care: The Health Care Team
- Primary Providers: Physician, Physician Assistant, APRN.
- Nursing Staff: Nurse, Assistive Personnel.
- Specialty Therapists: Physical, Occupational, Speech, and Respiratory therapists.
- Support Services: Dietitian, Pharmacist, Chaplain/Spiritual Care Provider.
Trends and Ethical Considerations
- Trends to Watch:
* Focus on preventive care.
* Engaged and knowledgeable consumers.
* Mobile health (mHealth).
* Racial justice and equity in care delivery.
- Ethical Debates (Health Care: A Right, Privilege, or Obligation?):
* Should those who engage in risky behaviors or fail to make lifestyle changes deserve the same care as those with healthy lifestyles?
* Who pays for the care of the homeless and unemployed?
* Is public solicitation for organs (e.g., via TV) fair to those on waiting lists?
* Should taxes or premiums rise to pay for overdose intensive care?
* Should undocumented workers have the same access as U.S. citizens?
* COVID-19 distribution priorities: How to rank ability to pay, age, prisoners, nursing home residents, and essential workers?
* Should vaccination status determine the allocation of scarce resources like ventilators or critical care beds?
* How are decisions made when demand for organs (e.g., hearts) exceeds supply?
- Changing healthcare landscapes allow nurses to shape future delivery models.
- Nurses are a growing voice in proposing solutions for national health problems.
- Increase in advanced education: More nurses are pursuing APRN, DNP, or PhD degrees.
- Core focus: Nurses provide holistic care essential to health promotion and illness prevention.