Health Care Delivery System Pt. 2

• 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

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)

  • Professional Licensure (RN)

Agency for Healthcare Research & Quality (AHRQ)

• Develops tools for health care providers to improve safety, quality, and patient engagement in hospitals, physician offices, and nursing homes

• HCAHPS survey

  • A national standard survey which enables comparisons

• TeamSTEPPS

  • Helps team performance across the HCD system

RN Licensure

• Protects public

• Grants permission to an individual to engage in nursing after determining eligibility

• State-Run Boards of Nursing

  • Ensures minimal standards met

    • NCLEX, background checks

  • Advance safe, quality care through licensure, certification, education, and accountability for public protection

Quality & Safety Initiatives

The Joint Commission (TJC)

• Develops national patient safety goals

• Improves:

  • Patient ID

  • Communication

  • Safety of medication use

  • Safety of clinical alarms

  • Reduces HAIs

  • Safety risks

  • Enforces Universal Protocol

To Err is Human Report (1999)

• Highlights thousands of deaths due to preventable medical errors.

• Most errors due to FAULTY SYSTEMS

Crossing the Quality Chasm (2001)

• Lacking in health care safety and quality

• More errors cause an increase in cost

The Future of Nursing

• Nurses should:

  • Practice to the full extent of their education

  • Achieve higher levels of education

  • Be full partners with physicians

• 9 Recommendations

• Change at both the individual and system levels

• A call for action

Quality and Safety Education for Nurses (QSEN)

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

  • PCC

  • Teamwork and Collaboration

  • Evidence-Based Practice

  • Quality Improvement

  • Safety

  • Informatics

ANA

• Current nursing outcomes:

  • Staff Mix

  • Nursing Hours/ Patient Day

  • RN job satisfaction

  • Education

  • Turnover

  • Patient Falls

  • Pressure Ulcers

  • Patient Assault Rate

  • Restraint prevalence

  • HAIs

Magnet Certification

• Hospital Must:

  • Promote quality care

  • Identify excellence in the delivery of nursing services to patients

  • use evidence-based practice