Health Care Delivery System Notes

Overview of the Health Care Delivery System

• Nurses provide Nursing care, not medical care

• Communication between layers and providers is key

• Focus on patient OUTCOMES

• Goals of Health Care Delivery

  • Triple Aim:

  • Lower costs

  • Increase quality

  • Provide population health

• Access Barriers:

  • Cost

  • Geography

  • Trust

• Health Care Financing:

  • Private Insurance: Employer-sponsored, Managed care, Prospective payment.

  • Government Health Care Options: Medicare, Medicaid, Tricare, Veterans Administration.

Insurance Overview

• Employer-Based Plans:

  • Most Americans have managed care health plans partially paid by their employer.

  • Examples include: Cigna, Care First, Kaiser Permanente, UnitedHealth Group, Humana.

• Government Health Insurance:

  • Medicare: Federal coverage for individuals over 65 and those with certain disabilities.

  • Medicaid: A combination of state and federal coverage for low-income individuals, expanded through the Affordable Care Act (ACA).

  • Tricare/Veterans Administration: Coverage for military personnel.

The Affordable Care Act (ACA)

• Expanded Medicaid eligibility.

• Created health insurance exchanges.

• Prohibited denying coverage for pre-existing conditions.

• Allows children to remain on parents' insurance until age 26.

Health Care Payment Models

• Fee for Service (FFS):

  • Each service generates a fee. Higher service volume leads to higher fees.

  • Insurance typically covers 80%; individuals cover 20%.

• Prospective Payment:

  • Fixed amounts determined in advance for procedures based on diagnosis-related groups (DRGs).

• Capitation:

  • Fixed payment per individual regardless of service use.

Issues and Trends in Health Care Delivery

• Focus on quality, safety, and patient-centered care.

• Nursing's role in transforming health care:

  • Cultivate a more educated and involved patient base.

Oversight and Regulation

• Government Agencies for Quality Control:

  • Protects against unsafe practices and controls costs.

  • Standardizes practices to improve quality.

• Key Agencies:

  • Department of Health and Human Services (HHS)

  • Centers for Medicare and Medicaid Services (CMS)

  • Food and Drug Administration (FDA)

  • Agency for Healthcare Research and Quality (AHRQ)

  • National Institutes of Health (NIH)

Quality Initiatives

• The Joint Commission (TJC):

  • Develops national patient safety goals, enhancing communication, and safety protocols.

  • Focus on reducing healthcare-associated infections and enforcing universal safety protocols.

• To Err is Human Report (1999):

  • Highlights thousands of deaths due to preventable medical errors.

Patient-Centered Care

• Definition: Care that is respectful of and responsive to individual patient preferences, needs, and values.

• Involves patients as an integral part of care teams.

• Focus on personalized care plans and support self-management.

The Future of Nursing

• Recommendations from the Future of Nursing report (2011, 2020-2030):

  • Nurses to practice within full extent of education and training.

  • Need for greater equity in healthcare delivery.

  • Advocacy for patient engagement and quality improvement.

Quality and Safety Education for Nurses (QSEN)

• Developing Knowledge, Skills, and Attitudes (KSAs) to enhance:

  • Patient-Centered Care

  • Teamwork and Collaboration

  • Evidence-Based Practice

  • Quality Improvement

  • Safety

  • Informatics

Summary Points

• Healthcare delivery is influenced by many elements like regulations and quality benchmarks.

• An ongoing balance is necessary between quality improvement and managing costs.

• Nurses play a critical role in understanding care delivery mechanics, including who receives care, what is delivered, and how.