CHAPTER 11-Health Care Delivery System
Learning Outcomes
Identify elements of a well-functioning health care delivery system
Provides safe, effective, patient-centered, timely, efficient, and equitable care
Coordinates services across settings and providers to prevent fragmentation
Uses evidence-based practice and quality metrics to guide care delivery
Ensures access to preventive, acute, chronic, and end-of-life care
Maintains cost control and accountability through organized systems and payment models
Describe strategies to increase access to affordable, high-quality care
Expansion of insurance coverage through public and private programs
Use of primary care models to improve prevention and early intervention
Emphasis on care coordination and continuity of care
Implementation of value-based payment systems
Development of community-based and outpatient services
Compare and contrast health care delivery systems
Health care providers and hospitals: Focus on acute and specialty services
Multispecialty practice groups: Multiple specialties under one organization
Community health centers: Serve underserved and vulnerable populations
Prepaid group practices: Fixed payment for defined services
Accountable care organizations (ACOs): Provider networks accountable for cost and quality
Medical homes: Primary care–centered, coordinated, patient-focused care
Medical neighborhoods: Collaboration between primary care and specialists
Evaluate four basic ways to pay for health care
Fee-for-service: Payment for each service delivered
Managed care: Controls costs through provider networks and utilization review
Value-based purchasing: Payment tied to quality and outcomes
Government-funded programs: Medicare, Medicaid, and entitlement systems
Compare and contrast health care settings and facilities
Inpatient settings: Hospitals and acute care facilities
Outpatient settings: Clinics, ambulatory centers, same-day services
Extended-care services: Long-term and rehabilitative care
Home and community-based care: Care delivered outside institutional settings
End-of-life care settings: Hospice and palliative services
Describe members of the interprofessional health care team
Nurses and advanced practice registered nurses
Physicians and physician assistants
Pharmacists
Social workers and case managers
Physical, occupational, and respiratory therapists
Dietitians and other allied health professionals
Discuss selected trends and issues affecting health care delivery
Health care reform and cost containment
Shift from inpatient to outpatient care
Emphasis on quality improvement and patient safety
Increased use of technology and data tracking
Workforce shortages and scope-of-practice debates
Describe the role of nursing in health care reform
Delivering safe, high-quality, patient-centered care
Coordinating care across settings and providers
Participating in quality improvement initiatives
Advocating for patients within complex systems
Practicing to the full legal scope of nursing practice
Nursing Concepts
Health care systems
Structure through which health services are organized, delivered, and financed
Determines access, continuity, and quality of care
Directly affects nursing roles, workflow, and accountability
Health policy
Laws and regulations governing health care delivery and financing
Shapes scope of practice, reimbursement, and access to care
Nurses must comply with and advocate within policy frameworks
Quality improvement
Continuous processes to improve patient outcomes and safety
Uses data, benchmarks, and performance measures
Central to modern health care delivery and nursing accountability
Key Terms
accountable care organization (ACO)
Network of providers responsible for quality and cost of care
Nurses coordinate care to prevent duplication and readmissions
advanced practice registered nurses (APRNs)
Nurses with advanced education and expanded scope
Provide primary and specialty care services
ambulatory care
Health services provided without hospital admission
Nurses manage assessments, education, and follow-up
care coordination
Organized management of patient care across services
Nurses ensure continuity and safe transitions
community health centers
Provide primary care to underserved populations
Nurses deliver preventive and chronic care services
consumer
Individual receiving health care services
Nurses support informed decision-making
diagnosis-related groups (DRGs)
System classifying hospital cases for payment
Influences length of stay and resource use
entitlement reform
Changes to government benefit programs
Affects patient access and coverage
extended-care services
Long-term and rehabilitative care settings
Nurses manage chronic conditions and functional needs
fee-for-service
Payment for each service provided
May incentivize higher service volume
Health Insurance Marketplace
Platform for purchasing private insurance plans
Nurses assist patients with navigation and education
health maintenance organizations (HMOs)
Managed care plans with restricted provider networks
Nurses follow utilization guidelines
high reliability organizations
Systems designed to minimize errors
Nurses follow standardized safety practices
hospice
Care for terminally ill patients focusing on comfort
Nurses manage symptom control and family support
inpatient
Care requiring hospital admission
Nurses provide continuous, acute care
managed care
System controlling costs and access
Nurses coordinate care within plan limits
Medicaid
Government insurance for low-income populations
Nurses deliver care within eligibility rules
medical home
Primary care–centered model emphasizing coordination
Nurses act as care managers
medical neighborhood
Network supporting the medical home
Nurses facilitate communication between providers
Medicare
Federal insurance for older adults and eligible populations
Nurses must understand coverage rules
multipayer system
Health care financed by multiple sources
Creates complexity in coverage and billing
multispecialty group practice
Providers from multiple specialties in one organization
Supports coordinated specialty care
outpatients
Patients receiving care without admission
Nurses focus on education and follow-up
palliative care
Symptom management for serious illness
Nurses address comfort and quality of life
Patient Protection and Affordable Care Act (PPACA)
Law expanding coverage and reforming delivery
Affects insurance access and preventive care
pay for performance
Payment linked to quality outcomes
Nurses influence performance metrics
preferred provider organizations (PPOs)
Plans offering provider choice with cost differences
Nurses assist with care coordination
quality
Degree to which care improves outcomes
Core measure of nursing practice
respite care
Temporary relief for caregivers
Nurses support family caregiving systems
single-payer system
One entity finances health care
Simplifies payment but alters delivery structure
value-based purchasing
Payment based on outcomes and efficiency
Nurses play key roles in achieving quality targets
Introduction
Designing and delivering health care for a diverse population is a systems problem with three constant pressures: access, quality, and cost
U.S. health care experiences differ based on insurance status and financial resources, affecting early treatment, prevention, and outcomes
COVID-19 highlighted inequities in disease burden and resource distribution, especially in communities of color, making equity a system-level issue
Ongoing debate frames health care as either:
a public good/obligation (similar to sanitation/education)
or a market commodity (purchased based on ability to pay)
Nursing practice is directly affected by decisions made by government, insurers, and health care institutions
Nursing’s system role is to keep care patient- and family-centered while operating inside a business-driven system
Health Care: The Big Picture
A high-functioning system targets these outcomes: safe, effective, efficient, patient-centered, timely, equitable
System improvement requires aligning:
care processes (how care is delivered)
measurement (how performance is tracked)
incentives (how payment and accountability are structured)
Health care redesign frameworks connect outcomes to:
patient experience
population outcomes
cost control
workforce impact
FIGURE 11-1 — IHI Triple Aim (and expansion to Quadruple Aim)
What it shows
Framework linking three simultaneous goals:
improve patient experience (quality + satisfaction)
improve population health
reduce per-capita cost
What nurses must know
Systems are expected to improve all three dimensions at once (not “pick one”)
Quadruple Aim adds workforce well-being/job satisfaction as a required system target
How it appears on exams
Identify/label the aims
Match an intervention to the correct aim (experience vs population vs cost vs workforce)
QSEN Reflective Practice: Cultivating QSEN Competencies
Removed patient narrative per rules
Testable QSEN-linked elements
Patient-centered care requires:
education matched to patient understanding
acknowledging barriers (e.g., affordability)
shared decisions when feasible
Teamwork/collaboration requires:
escalating to appropriate team member when information exceeds role/competence
using interpreter/language-appropriate communication when needed
Safety/EBP requires:
ensuring discharge teaching supports adherence
using reliable resources rather than guessing
Professional accountability requires:
working within supervision requirements when under another license
seeking help rather than fabricating information
Exam appearance
“Best action” questions: do not invent data; consult appropriate resource/person; ensure culturally/linguistically appropriate communication
A “learning health care system” is described as one that aligns:
science + informatics
patient–clinician partnerships
incentives + culture
continuous real-time improvement in effectiveness and efficiency
Major system challenges highlighted include:
persistent inequities
aging population
emerging threats
fragmented/discontinuous care
high cost and waste
innovation constraints from outdated approaches
System tools emphasized:
delivery + financing redesign
stronger population/community focus
improved individual/family engagement
technology/telemedicine
“big data” for improvement
Access to Health Care
Access exists when people can obtain needed care; depends on:
ability to pay
availability of services
PPACA goal: reduce uninsured through:
Medicaid expansion/subsidized coverage for qualifying incomes (up to defined thresholds)
standardized access to plans through the Health Insurance Marketplace
Marketplace plan expectations described:
comprehensive coverage across major service categories
comparison across plans by price/benefits/quality/features in plain language
Reported access barrier despite reform: cost of coverage remains a major reason people stay uninsured
Coverage is affected by:
employment changes
state policy differences (e.g., Medicaid eligibility decisions)
eligibility exclusions (e.g., undocumented status)
Box 11-1 — Summary: Key Facts about the Uninsured Population
What it shows
size and recent changes in the uninsured population (nonelderly)
common characteristics of uninsured populations
primary reasons coverage is absent
consequences for access and finances
What nurses must know
uninsured status correlates with:
delayed/foregone care due to cost
lower preventive service use
higher likelihood of medical debt
uninsured populations are more likely to include:
low-income families
adults (vs children) depending on public coverage availability
people of color at higher risk compared to non-Hispanic White people
How it appears on exams
Identify reasons for uninsurance (cost, job coverage gaps, eligibility limits)
Link uninsurance to outcomes (preventive care gaps, delayed treatment, financial harm)
Shortage of Providers
Large populations live in areas with inadequate primary care access due to workforce shortages
Primary care supply concerns include:
fewer physicians choosing primary care
aging primary care workforce nearing retirement
mismatch between primary-care visit demand and workforce entry
Nurse practitioners are presented as a workforce solution based on:
quality of care
patient satisfaction
accessibility
affordability
Nursing workforce demand projections:
growth in RN demand outpacing supply
major driver: aging population and increased service need
Legislation Addressing Health Care Access
PPACA reduced uninsured numbers but faced persistent political opposition and repeal efforts
Professional advocacy noted:
nursing organizations oppose policy changes that increase uninsured rates or reduce Medicaid access
Vulnerable Population Alert: Caring for Persons Who Are Undocumented
Undocumented immigrants are excluded from most federal health insurance programs (as described)
Limited federal funding allowed:
emergency stabilization services (hospital requirement to stabilize life-threatening conditions)
Common care access route described:
federally funded community health centers with sliding-scale services
Nursing implications in clinical/community settings:
anticipate reduced care-seeking behavior due to fear/policy climate
provide care consistent with legal requirements and ethical obligations
connect patients to eligible services/resources within policy limits
Exam appearance
priority: stabilize emergencies; do not deny legally required care
identify realistic access pathways (community health centers, emergency coverage limits)
Quality and Safety
Medical errors were framed as a major preventable harm source, linked to system fragmentation
System-level safety strategy described in four parts:
national leadership focus (research/tools/protocols)
error identification and learning (mandatory + voluntary reporting)
raising performance standards via oversight/professional groups/purchasers
implementing organizational safety systems
Quality definition in health care:
care that increases likelihood of desired outcomes and aligns with professional knowledge
operational shorthand: right care, right person, right time
Quality measurement is used for:
public evaluation of facilities/providers
reimbursement decisions
Reliable Care Accountability Matrix
High reliability organizations operate in high-risk settings with sustained safety performance
Core characteristics listed:
focus on preventing failure
avoiding oversimplification
operational awareness
deferring to expertise
resilience commitment
Nurses’ system role:
translate evidence-based practices into consistent frontline care
reinforce standardized processes tied to safety outcomes
FIGURE 11-4 — Reliable Care Accountability Matrix (RCAM)
What it shows
standardized core clinical processes tied to specific quality outcome domains
What nurses must know
standardization is used to reduce variation and improve outcomes
validation methods include:
outcome data review
direct observation
chart audits
interviews
examples of standardized tactics include nurse-driven protocols and order set utilization monitoring
How it appears on exams
identify why standardization supports safety/quality
connect audits/validation to accountability and improvement
Pay for Performance/Value-Based Purchasing
Pay for performance: financial incentives tied to payer goals (efficiency, data reporting, quality, safety)
Value-based purchasing: redistributes part of payment based on performance on quality measures (described for Medicare inpatient services)
HEDIS (NCQA tool): standardized measures used widely by health plans to compare performance across defined domains
HCAHPS:
national standardized survey of patient perspectives of hospital care
enables comparisons across hospitals
focuses on whether key care experiences occurred (not general “satisfaction”)
Public reporting includes measures such as:
nurse/physician communication
staff responsiveness
pain management support
medication communication
discharge information
cleanliness/quietness
overall rating and recommendation
Star ratings format:
summarizes performance across measure groups (mortality, safety, readmissions, patient experience, effectiveness, timeliness, imaging efficiency)
Penalties for Excess Readmissions
Hospitals may face reimbursement penalties for high readmission rates
Readmissions are treated as an indicator of:
poor coordination
high cost
weak transition planning
Exam appearance:
link discharge planning/care transitions to readmission risk and reimbursement consequences
Affordability
How Health Care Is Financed
Financing has two streams:
collection of funds (“money in”)
reimbursement to providers (“money out”)
U.S. is a multipayer system:
private insurers + government payers
private role dominates compared to many countries
High national health spending affects other societal budget priorities
Single-payer model is presented as a proposed solution to:
reduce administrative waste
consolidate billing/payment
Table 11-1 — Strategies to Reduce Health Care Costs
What it shows
reimbursement/regulatory strategies and care-delivery strategies aimed at cost reduction
What nurses must know
Reimbursement/regulatory strategies include:
prospective payment systems (DRGs; RUGs for long-term care)
capitation/managed care (fixed payment per enrollee; provider assumes financial risk)
bundled payments (fixed sum for a range of services)
rate setting (targets/caps; standard pricing/payment approaches)
comparative effectiveness analysis (cost-benefit decisions on technologies/coverage)
increased patient cost sharing (higher deductibles; may reduce necessary care use)
Care-delivery strategies include:
quality improvement tools to reduce waste and improve safety (Lean Six Sigma, PDSA)
improved transitions to reduce 30-day readmissions
coding changes (ICD-10) to improve data quality for QI/payment
fraud/abuse reduction (nursing role includes reporting suspected fraud/abuse)
population health focus to reduce long-term disease burden
How it appears on exams
match strategy to description (e.g., DRG = fixed payment by diagnosis)
identify risks (e.g., cost-sharing can block needed care; capitation can pressure underuse)
How the U.S. Health Care Dollar Is Spent
FIGURE 11-5 — How the U.S. health care dollar is spent
What it shows
distribution of national health expenditures (pre–COVID-19 reference point)
What nurses must know
major spending categories include hospital care and clinical/provider services
ongoing policy pressure: shift spending toward community prevention and away from avoidable hospital costs
How it appears on exams
recognize that system reform targets community investment and prevention to reduce high-cost downstream care
How the U.S. Health Care System Compares Internationally
U.S. described as:
highest cost system among peers
underperforming in key performance dimensions (quality, access, efficiency, equity, healthy lives) in comparative reports
Comparative highlights described:
higher spending share of economy than peers
lower life expectancy and higher suicide rates among comparison group
higher chronic disease burden and obesity prevalence compared with OECD average
fewer physician visits than peers (linked to physician supply)
higher use of expensive technology and specialized procedures
stronger performance on some preventive measures (e.g., screening and vaccination examples)
higher rates of preventable hospitalizations and avoidable deaths
FIGURE 11-6 — How commercial health plans spend premium dollars
What it shows
allocation of premium dollars across categories (e.g., medical care vs administrative components)
What nurses must know
premiums are not fully spent on direct patient care; a portion supports administrative functions and other costs
How it appears on exams
questions distinguishing system “administrative costs” vs direct care spending
Health Care Reform
PPACA intent described:
expand coverage
control costs
improve the delivery system
Nurses are expected to understand how reform affects:
clinical practice environment
care delivery structures
public coverage choices
Nursing organizations support reforms aimed at:
preserving coverage
improving access to primary and preventive services
Box 11-2 — Nurses Can Make a Difference in Health Care Policy and Reform
What it shows
specific professional actions nurses can take to influence policy and reform
What nurses must know
actions listed include:
staying current on issues/legislation
communicating with lawmakers
participating in nursing organizations
documenting outcomes of nursing care for cost/quality databases
contributing to innovative delivery model design/implementation
leadership in nursing and consumer groups
advocating for equal/affordable/access-to-knowledgeable-care
supporting universal access to essential services
strengthening primary/community/preventive services
supporting cost-effective use of technology-driven hospital services
encouraging economic use of services while supporting those unable to share costs
ensuring adequate skilled workforce supply
How it appears on exams
identify nurse advocacy behaviors vs non-nursing policy roles
link outcome documentation to cost/quality influence
Organizing Health Care: Primary, Secondary, and Tertiary Care
Health care is organized into three levels with different goals, providers, and settings
Resource allocation tension:
disproportionate spending on secondary/tertiary care reduces investment in prevention/primary care
Care coordination includes:
right care + right patient + right time + right provider (as framed)
Table 11-2 — Primary, Secondary, and Tertiary Health Care
What it shows
care level, goal, typical practitioners, practice sites, and core activities
What nurses must know
Primary care
common problems + prevention that comprise most clinical visits
sites include primary care/urgent care/employment health centers/family planning centers
activities include health education, screenings, immunizations, meds, prenatal/well-baby care, diagnostic testing
practitioners include family practice physicians, NPs, midwives
Secondary care
specialized expertise (e.g., hospital care for major acute events)
sites include hospitals, EDs, hospital clinics, same-day surgery, psychiatric institutes
practitioners include specialty physicians and advanced practice nurses
Tertiary care
rare/complex disorder management
sites include tertiary medical centers
practitioners include subspecialists and advanced practice nurses
How it appears on exams
match scenario to care level and setting (primary vs secondary vs tertiary)
Through the Eyes of a Nurse
Removed narrative per rules
Testable system points contained in the display
nurse leadership is often underrepresented in policy/reform forums despite system impact
nurse-led care coordination is linked to cost reduction (as presented)
nurse staffing mix and RN proportion are linked to outcomes (falls, complications, mortality) and cost
patient experience measures affect reimbursement; nursing care influences patient experience domains
expanding APRN and midwifery access is presented as a strategy to improve access and control costs
Organizing Health Care: Health Care Delivery Systems and Care Coordination
U.S. delivery historically described as fragmented across:
national/state/community/practice levels
System fragmentation problems described:
patients/families navigate across settings without structured support
unclear accountability across multiple providers contributes to errors, duplication, and waste
weak QI infrastructure and poor clinical information systems reduce quality
incentives reward high-cost interventions over primary care, prevention, and chronic disease management
Nurses are positioned as key contributors to improved care coordination across settings
Health Care Providers and Hospitals
Historically common structure:
fee-for-service providers in solo/small groups
hospitals often not-for-profit community institutions
providers not employed by hospitals held strong influence via admissions/referrals
Fee-for-service incentive pattern:
payment increases with more services delivered, not necessarily better coordination or outcomes
Exam appearance:
identify how fee-for-service can encourage volume and fragmentation
Multispecialty Group Practice
Developed to address growing complexity of drugs/technology and need for coordinated specialty services
Structure:
multiple specialties share resources (income/expenses/facilities/equipment/support staff)
Supports comprehensive care beyond what a generalist can provide alone
Community Health Centers
Regionalized services emphasizing:
primary care
education
access regardless of ability to pay
Serve vulnerable geographic populations; rely heavily on nurses for primary care delivery
Positioned as cost-saving by supporting early treatment and preventing avoidable ED use
Prepaid Group Practice
HMO model
prepaid managed care plan with affiliated providers
patient typically uses plan-associated clinicians; limited provider choice
costs may include small copayments and fewer additional out-of-pocket charges
prevention and primary care emphasized to reduce costs
PPO model
payer contracts with provider group for lower fees in exchange for prompt payment and patient volume
patients can go outside the network with higher out-of-pocket costs
Point-of-service concept (as described)
encourages use of specified providers but covers some outside referrals under plan rules
Exam appearance:
compare HMO vs PPO on provider choice, network restrictions, cost-sharing patterns
Accountable Care Organizations
ACOs are presented as a shift away from fee-for-service incentives
Structure:
combined organizations (hospital + primary + specialty) responsible for a defined population
care integrated across settings with one consolidated billing structure (as described)
Incentives:
shared savings when quality and efficiency improve
Nursing role:
care coordination across settings aligns with ACO goals and population health accountability
Medical Homes to Medical Neighborhoods
Medical home (PCMH)
enhanced primary care model providing:
whole-person, accessible, comprehensive, ongoing, coordinated, patient-centered care
linked to Quadruple Aim orientation in the conceptual model reference
Medical neighborhood
PCMH plus other clinicians and community/social/public health resources surrounding the patient
intended to address individual needs while incorporating population/community needs
Ongoing system problem described:
medical neighborhood remains fragmented with poor coordination and weak incentives for coordination under fee-for-service
FIGURE 11-7 — Conceptual framework for effectiveness of the medical home
What it shows
model linking PCMH structure/process to outcomes (effectiveness framework)
What nurses must know
PCMH is evaluated using outcome-linked components (coordination, access, comprehensive primary care)
How it appears on exams
identify features of a medical home vs traditional primary care
FIGURE 11-8 — Medical neighborhood
What it shows
PCMH at the center with surrounding specialist, community, and public health supports
What nurses must know
medical neighborhood requires structured coordination to prevent fragmentation
How it appears on exams
distinguish “medical home” from “medical neighborhood” by scope and partners
Care Coordination
Defined as deliberate organization of care activities among two or more participants (including the patient) to ensure appropriate service delivery
Requires:
marshaling personnel and resources needed for required care activities
information exchange among participants responsible for different aspects of care
Nursing role:
nurses are identified as essential to coordination strategies across settings
Paying for Health Care
Four basic payment modes listed:
out-of-pocket payment
individual private insurance
employer-based group private insurance
government financing
Out-of-Pocket Payment
Historically common but now less common due to high health care costs
Public expectation described:
basic health care needs should be met regardless of ability to pay
Individual Private Insurance
Purchased through nonprofit or for-profit insurers
Financed by premiums paid by individuals and/or employer contributions
Considered “third-party payment” because insurer pays all/most costs
Typically allows greater choice of providers/services compared with managed care plans (as described)
Employer-Based Private Insurance
Most common coverage source in the U.S. (as framed)
Coverage offers differ by:
full-time vs part-time status
income level (declines greater among low/modest income families)
Trend described: decline over time in proportion of workers offered coverage
Government Financing
Major federally funded programs listed:
Medicare
Medicaid
Children’s Health Insurance Program (CHIP)
Veterans Health Administration (VHA)
Medicare
Established as national/state insurance for older adults under Title XVIII
Eligibility expanded to include permanently disabled workers/dependents meeting Social Security criteria (as described)
Shift to prospective payment using DRGs to control costs
Reimbursement linked to:
fixed payment by diagnosis/procedure category
later adjustments incorporating severity and projected cost (as described)
Nonpayment policy for preventable hospital-acquired conditions described, including:
pressure injuries
fall-related injuries
catheter-associated urinary tract infections
vascular catheter–associated infections
mediastinitis after coronary artery bypass graft
air embolism
reactions to incompatible blood transfusions
retained surgical items
Coverage structure described:
Part A: primarily inpatient hospital costs (government-funded)
Part B: voluntary, premium-based; outpatient costs including physician visits, medications, home health (as listed)
deductibles and premiums apply; supplemental private coverage recommended due to incomplete coverage
Policy volatility described:
benefits may change with federal budgeting decisions
entitlement reform debates affect program sustainability discussions
Exam appearance:
DRG meaning and incentive effects
Medicare payment consequences for preventable errors (quality/safety + reimbursement)
Medicaid
Public assistance program under Title XIX for:
low-income people (any age)
blind, older adult, and disabled people covered by supplemental security benefits (as described)
beneficiaries under specified family assistance programs (as described)
Eligibility and benefits vary by state regulations
Budget pressures described drive program changes such as:
benefit reductions
movement into managed care programs
Children’s Health Insurance Program (CHIP)
Created to insure low-income children not eligible for Medicaid and unable to afford private insurance
Federally supported with enhanced matching support to states (as described)
Serves large numbers of children alongside Medicaid; coverage gaps persist due to eligible-but-not-enrolled children
Veterans Health Administration (VHA)
Largest integrated health care system described, including:
medical centers
community-based outpatient clinics
community living centers
veterans’ centers
domiciliaries
Provides comprehensive care to millions of veterans annually with a large practitioner workforce and substantial annual appropriation
Health Care Settings and Services
Health care is delivered in multiple facilities to match different patient needs
Most services occur outside hospitals because hospitalization is mainly for:
complex surgery
acute illness/serious injury
some births
short duration stays
Non-hospital settings listed include:
clinics, homes, schools, prisons
daycare centers (children/older adults)
crisis-intervention centers, mental health centers
substance rehabilitation programs
storefront clinics, churches
Hospitals
Community hospitals: short-term, general, nonfederal, and special hospitals (e.g., orthopedic, cancer, academic medical center)
Reported scope indicators:
admissions, emergency department volume, and births occur at high frequency
Hospital stays are typically short; longer stays occur with:
serious infections
major trauma
mental illnesses
cardiovascular diseases
Drivers of shorter stays include:
improved disease treatment
emphasis on preventive care
federal regulations
reimbursement policy
Shorter stays shift hospital care toward acute care needs
Nursing discharge responsibility:
ensure patients and family caregivers are prepared to meet care needs by discharge
Classification
Hospitals classified by:
public vs private
for-profit vs nonprofit
Public hospitals:
nonprofit
financed/operated by local/state/national governments
may serve patients without insurance
services at little/no cost to patient
covered by tax/public funds
Private hospitals:
may be for-profit or nonprofit
operated by communities, churches, corporations, charitable organizations
Catholic health ministry:
identified as the largest nonprofit health care provider group nationally
described as caring for a substantial proportion of U.S. patients daily
Insurance patterns:
private hospitals commonly serve patients with personal insurance or a health care plan
Size and Services
Bed capacity ranges from small hospitals (~20 beds) to large medical centers (hundreds of beds)
Core services commonly offered:
emergency care
inpatient care
surgery
diagnostic testing
patient education
Additional services may include:
intensive care
obstetric care
palliative care
social services
outpatient clinics and outpatient surgery
educational programs
long-term skilled nursing care facilities
Hospitals may be:
general (all types of illness/trauma)
specialty-focused or have specialty units
Specialty focus examples include:
pediatrics
rehabilitation
cancer care
psychiatric care
drug-dependency care
burn care
Inpatient and Outpatient Services
Inpatient
enters hospital and stays overnight
length of stay may range from days to months
Outpatients
receive diagnosis/treatment without overnight hospitalization
services include:
procedures (including surgical)
diagnostic tests
medications
physical therapy
counseling
health education
Short-stay outpatient unit model:
diagnostic test/surgery → brief recovery (1–6 hours) → discharge home
Outpatient classification may include:
admitted, treated, discharged within 23 hours
Nurses’ Role in Hospitals
Hospitals remain the largest employer category for nurses, with a declining percentage over time
Projected trend:
fewer RNs employed in hospitals
more RNs employed in outpatient, home health, and long-term care
Hospital nursing roles include:
direct care provider
manager/supervisor of care team members
administrator
nurse practitioner
clinical nurse specialist
patient educator
in-service educator
researcher
Magnet Recognition Program and Pathway to Excellence Program (ANCC)
Administered by the American Nurses Credentialing Center (ANCC)
Magnet designation requires strict standards defining high-quality nursing practice and patient care
Magnet designation recognizes:
quality patient care
nursing excellence
innovations in professional nursing practice
Primary Care Centers
Primary care services delivered in offices/clinics by:
health care providers
advanced practice nurses
Services include:
diagnosis and treatment of minor illnesses
minor surgical procedures
obstetric care
well-child care
counseling
referrals
Federally qualified health centers (FQHCs) / community health centers:
nonprofit primary care clinics in high-need areas
serve everyone regardless of insurance or ability to pay
often offer on-site mental health and dental services
RN role in provider office:
conducts health assessments
performs technical procedures
assists the provider
provides health education and counseling
FIGURE 11-9 — Well-child visit at a primary care center
What it shows
nurse conducting assessment during a well-child visit
What nurses must know
primary care nursing includes assessment and preventive services
How it appears on exams
identify primary care setting roles: assessment, counseling, education, support of prevention
Advanced Practice Registered Nurses (APRNs)
APRNs are RNs educated at master’s or post-master’s level
APRN roles listed:
nurse practitioners
midwives
clinical nurse specialists
Practice structure:
work independently or collaboratively with providers
Scope note:
state regulations determine whether APRNs can operate independent practices/clinics
Patient care focus includes:
assessment and care for health maintenance/health promotion
referral of complex problems to providers
Ambulatory Care Centers and Clinics
Provide outpatient medical care
Located:
within hospitals or freestanding
in convenient community locations (e.g., shopping malls)
Access features:
walk-in services (appointments unnecessary)
extended hours beyond traditional office times
Leadership:
may be managed by an APRN
Nontraditional sites:
small APRN-staffed clinics in drugstores/grocery stores
Access impact:
improve access for uninsured and those with barriers to care
Nursing role in ambulatory settings:
technical services (e.g., medication administration)
prioritization of care needs
patient teaching on all aspects of care
Urgent care center:
walk-in care for illnesses and minor trauma
Same-day/outpatient surgical centers:
identified as another ambulatory care form (separately discussed elsewhere)
Home Health Care
Identified as a rapidly growing health care area
Delivery channels include:
community health departments
visiting nurses’ associations
hospital-based case managers
home health agencies
Services include:
skilled nursing assessment
teaching/support for patients and families
direct patient care
Growth drivers include:
prospective payment encouraging early hospital discharge
increased older adult population with multiple chronic illnesses
ability to live at home with sophisticated technology
consumer preference for humane services and dignified death at home
Home health nursing role includes:
assessment and physical care
medication administration
teaching
family support
collaboration with:
physicians
PT/OT
respiratory therapists
social workers
Extended-Care Services
Provide medical and nonmedical care for chronic illness/disability
Assist with activities of daily living for people unable to live independently
Long-term care utilization described as increasing with aging population
Majority of extended care is provided by family/friends, with many older adults not living in facilities
Nursing practice implication:
assess and respond to caregiver burden and caregiver needs
Duration:
ranges from days to years
Facility types include:
transitional subacute care
assisted living
intermediate and long-term care facilities
homes for medically fragile children
retirement centers
residential institutions for mentally/developmentally/physically disabled patients
“Aging in place”:
living at home or in independent living while able, with services added as needed over time
requires community commitment to meeting needs
Senior retirement communities:
range of services from independent living to skilled nursing
may include memory care for dementia
Drivers of growth in extended-care facilities:
earlier hospital discharge requiring care beyond home scope
aging population with fewer available caregivers and higher ADL dependence
Long-term care improvement drivers:
focus on maintaining function and independence
environment improvements and quality-of-life emphasis
increased quality assurance tied to OBRA 1987
Nursing roles in extended care may include:
direct care provider
supervisor
administrator
safety/quality nurse
teacher
Staffing/legal scope requirement:
skilled nursing care must be available at all times
care is performed only by or under direct supervision of a licensed nurse
Facility selection guidance list (AARP “before choosing a nursing home”):
safety/security assessment
resident/family feedback
culture assessment via direct questions
staff turnover check
meal observation
smell and sound assessment
safety check
off-hours visit
Specialized Care Centers and Settings
Provide services for specific populations/groups
Usually located in accessible community locations
Daycare Centers
Serve:
healthy infants/children of working parents
children with minor illnesses (some centers)
older adults needing socialization and supervised care during caregiver work hours
Some provide services for:
rehabilitation
functional needs (example given: cerebral palsy)
chemical dependency and mental health
Nursing role:
administer medications and treatments
conduct health screenings
teach and counsel
Mental Health/Behavioral Centers
May be hospital-associated or independent
Services may be:
crisis-centered
long-term counseling
Outpatient interventions include:
individual and group counseling
medications
assistance with independent living
Crisis intervention centers:
24-hour services and hotlines for:
suicidal individuals
substance use crises
abuse situations
support services for rape and abuse victims
Systems issue:
mental health services may be inadequately funded, limiting referral options
Nursing role:
strong communication/counseling skills
knowledge of community resources for appropriate referrals
Removed patient narrative per rules
Rural Health Centers
Located in remote areas with limited providers
Often run by APRNs providing:
primary care for minor acute illnesses
chronic illness management
Serious illness/injury:
emergency care then transport to larger hospital
Independent nursing practice may occur with provider collaboration
Technology:
telecommunication/computers support diagnosis/treatment access
Rural access facility types:
Critical access hospitals
fewer than 25 acute inpatient beds
more than 35 miles from another hospital
24/7 emergency care
average length of stay ≤ 96 hours for acute care patients
Freestanding emergency departments
affiliated with larger facility or independent
Nursing impact:
screening and education supports healthier lives in rural communities
Schools
School nurses as major source of:
health assessment
health education
emergency care for children
Role reflects:
increasing racial/ethnic diversity
socioeconomic variation
more complex disabilities requiring expert management in school hours
School nursing services include:
immunization record management
emergency care for physical/mental illness
medication administration
routine screenings (vision, hearing, scoliosis)
health information and education
Industry
Large industries may operate ambulatory clinics staffed primarily by nurses
Occupational health nursing focus:
prevent work-related injury/illness
health assessments
health promotion teaching (smoking cessation, nutrition, safety equipment use, exercise)
minor accident/illness care
referrals for serious problems
Homeless Shelters
Shelters provide housing for people without regular shelter
Increased health risks due to:
environmental exposure
violence exposure
substance use disorders
poor nutrition
poor hygiene
overcrowding
Nursing services include:
child immunizations
teaching pregnant women
treating infections/illnesses
STI referral for diagnosis/treatment
health maintenance education
Rehabilitation Centers
Specialize in:
physical rehabilitation
emotional rehabilitation
chemical dependency treatment
May be freestanding or hospital-associated
Goal:
return patients to optimal health and community independence
Team:
multidisciplinary (providers, nurses, PT, OT, counselors)
Nursing role:
direct care
teaching
counseling
Rehabilitation nursing philosophy:
encourage independent self-care within patient capabilities
Parish Nursing
Specialty emphasizing:
holistic care
health promotion
disease prevention
Combines nursing with health ministry in faith communities
Parish nurse functions:
health educator
resource and referral support
facilitator of volunteer/support groups
Outreach focus:
vulnerable groups (older adults, loss/change, single parents, children)
Health Care Services for the Seriously Ill and Dying
Services listed for patients/families/caregivers:
respite care
hospice
palliative care
Respite Care
Temporary care for caregivers of homebound ill/disabled/older adults
Purpose:
provide time away for primary caregiver responsibilities
Care location:
adult daycare center or patient home
Provider type:
qualified nursing assistants or volunteers (most instances)
RN role:
provide access information and referrals
Coverage:
Medicaid and most insurers do not cover respite care costs
Hospice Services
Hospice is palliative/supportive care providing:
physical, psychological, social, spiritual care
for dying people and their families/loved ones
Interdisciplinary hospice team functions include:
pain and symptom management
emotional/psychosocial/spiritual support
provision of drugs/supplies/equipment
family instruction for home care
specialty services when needed (speech/physical therapy)
short-term inpatient care when symptoms uncontrolled at home or caregiver needs respite
bereavement care/counseling for survivors
Payment source:
Medicare hospice benefit is predominant
Eligibility requirement for Medicare/Medicaid hospice:
serious progressive illness
life expectancy of 6 months or less
Hospice nurse role:
combines home care skills with daily emotional support
high skill in pain/symptom management
focus on quality of life and dignity
bereavement support for up to 1 year after death
Palliative Care
Origin:
evolved from hospice but extends beyond hospice programs
Timing:
not limited to end of life; can begin at diagnosis
Setting:
provided in all types of health care settings
Definition elements:
patient- and family-centered care
optimizes quality of life
anticipates, prevents, and treats suffering
Key features listed:
interdisciplinary team coordination
collaboration/communication among patient, family, and care providers
available alongside or independent of curative/life-prolonging treatment
supports hopes for peace and dignity through illness, dying, and after death
Health Care Facilities
Health care facilities discussed in this section:
voluntary facilities
religious facilities
government facilities
Voluntary Facilities
Community facilities are often nonprofit voluntary facilities
Funding sources:
private donations
grants
fundraisers
some charge minimal fees
Examples of volunteer facilities/services:
Meals on Wheels (meals for older adults and homebound people)
transportation for older adults and physically disabled people
shopping services
house-cleaning services
Other nonprofit voluntary community organizations:
American Heart Association
American Lung Association
Nursing/health care provider involvement:
active membership
provision of health screenings
delivery of educational programs
Voluntary facilities may host support groups
purpose: education + support for people adjusting to health problems
membership: individuals with the same type of problem
mechanism: shared experiences used to develop problem-solving in stress/crisis
nursing role: provide information and make referrals for patients/families
Examples of Support Groups
Alcoholics Anonymous (AA)
international organization for recovery from alcohol use disorders
purpose: stop drinking and maintain sobriety
meeting locations: accessible community sites (e.g., churches, hospitals)
Cancer support groups
focus: support and problem-solving for people diagnosed with cancer
meeting locations: commonly hospitals
Reach to Recovery
population: women post-mastectomy for cancer or post–breast reconstruction
activities:
preoperative visits
teaching exercises to prevent muscle atrophy
information on prostheses and clothing
Other Government Facilities
Additional government health facilities discussed beyond:
Medicare
Medicaid
Veterans Health Administration/Association
Public Health Service
Public Health Service (PHS):
federal health entity under U.S. Department of Health and Human Services
multifaceted program with wide-ranging services
PHS roles/functions listed:
medical branch of the U.S. Coast Guard
principal source of Native American health care via Indian Health Services
funds health centers providing care to migrant workers
funds community facilities providing care to poor and uninsured
major budget focus: grant programs for poor and uninsured populations
PHS agencies included:
CDC (Centers for Disease Control and Prevention)
focus: epidemiology, prevention, control, and treatment of communicable diseases (including STIs)
NIH (National Institutes of Health)
functions: funds and conducts health research activities
PHS workforce support roles:
supplies health care professionals (nurses, providers, dentists, pharmacists) to U.S. Department of Justice for care in federal prisons
involvement in some state-administered:
drug and alcohol use programs
mental health programs
PHS operational focus:
emphasis on community needs whenever possible
Nursing roles in PHS-related settings:
provide direct care
provide information
serve as patient advocates within the community
Reference to FIGURE 11-10:
illustrates 10 essential public health services
links services to addressing social determinants of health (SDOH) inequities
Public Health Facilities
Definition/structure:
local, state, and federal facilities delivering public health services at corresponding levels
Funding/administration:
usually funded by taxes
managed by elected or appointed administrators
Local public health services and programs:
promote health and prevent illness
immunizations
screening for tuberculosis and STIs
Public health protection activities:
inspections of restaurants
inspections of water supplies
Public health education:
provide educational programs
Direct care services may be provided to:
low-income populations
rural/isolated populations
Nursing focus areas in public health facilities:
prenatal care
well-child care
screening programs
education
community outreach
FIGURE 11-11 — Prenatal care at a public health clinic
What it shows
nurse providing prenatal care in a public health clinic setting
What nurses must know
public health nursing includes prenatal services and prevention-focused care
How it appears on exams
identify public health clinic scope: prevention, screening, prenatal/well-child services, outreach
Collaborative Care: The Interprofessional Health Care Team
Nurses collaborate with interprofessional team members to:
plan patient care
provide patient care
evaluate patient care
Collaboration is linked to improved likelihood of achieving valued patient outcomes
Collaboration referenced as applicable in:
any facility
any setting
any care framework
Box reference:
Box 11-3 lists collaborative roles of interprofessional team members
FIGURE 11-10 — Ten essential public health services and SDOH inequities
What it shows
10 essential public health services
integration points for addressing social determinants of health inequities across public health work
What nurses must know
public health practice should incorporate how living/learning/working/playing conditions affect health risks and outcomes
addressing inequities can be integrated across essential public health services
How it appears on exams
recognize that public health services include health equity and SDOH considerations as part of system-level practice
QSEN — Teamwork and Collaboration
Effective interprofessional teamwork requires each nurse to demonstrate:
awareness of personal strengths as a team member
awareness of personal limitations as a team member
initiation of self-development plans to improve team functioning
System-level initiative example (as stated):
U.S. Department of Health and Human Services awarded funding to support interprofessional education and collaborative practice
goal: promote a health care system engaging patients, families, and communities in collaborative, team-based care
Box 11-3 — Collaborative Roles of Members of the Interprofessional Health Care Team
Physician
Primary responsibilities:
diagnose illness
provide medical or surgical treatment
Institutional authority within facilities includes:
admitting patients (authority granted by facility/institution)
prescribing medications
interpreting lab/diagnostic results
performing procedures and surgery
Entry requirements:
extensive education + clinical practice + licensing exam
Practice types:
generalist or specialist (illness/body system or surgery type)
Hospitalists
Provide care for patients:
in the emergency department
when admitted to the hospital
Communication role:
communicate with patient’s primary care provider
Coverage role:
may provide after-hours/weekend/holiday coverage for one or more providers
Advanced Practice Registered Nurse (APRN)
Definition:
RN educated at master’s or post-master’s level for a specific role and population
Roles listed:
nurse practitioners
clinical nurse specialists
nurse anesthetists
nurse midwives
Practice positioning:
described as pivotal to the future of health care
often primary care providers
emphasized role in preventive care delivery
Physician Assistant (PA)
Preparation:
specific course of study + licensing exam
Function:
provides support to physician
Scope depends on supervising physician
Task examples:
physical examinations
suturing lacerations
Nursing legal/scope alert (testable):
in most states, nurses are not legally bound to follow PA orders unless physician cosigns
nurses must verify how PA orders function in their institution and state rules
Nurse
Core responsibilities:
supervise and coordinate direct care to patients and families
teach patient/family self-care
conduct research to support cost effectiveness and quality of care
coordinate services of other health care providers
Physical Therapist (PT)
Goal:
restore function or prevent further disability after injury/illness
Treatment methods listed:
massage
heat/cold
water
sonar waves
exercises
electrical stimulation
Additional preparation noted:
psychological strategies to motivate patients
Occupational Therapist (OT)
Functions:
evaluate functional level
teach activities to promote self-care in ADLs
assess home safety
provide adaptive equipment as needed
Speech Therapist
Functions:
improve speech clarity for deaf/hard of hearing patients
help post-stroke patients relearn speech
correct/modify speech disturbances (children/adults)
diagnose and treat swallowing problems after head injury or stroke
Social Worker
Focus:
social, emotional, environmental factors affecting well-being
Functions:
referrals to community resources
assist securing equipment and supplies
assist with health care finances
Current emphasis noted:
discharge planning role is highlighted
Pharmacist
Preparation:
doctoral level + licensure to formulate and dispense medications
Medication safety responsibilities:
maintain file of patient medications
inform provider when potential/actual prescribing medication error occurs
identify adverse drug interaction risks
Practice implication:
pharmacist is a resource for medication information for patients and nurses
Respiratory Therapist (RT)
Functions:
implement techniques to improve pulmonary function and oxygenation
administer lung function tests
educate patients on use of prescribed respiratory devices and machines
Dietitian (RD)
Functions:
plan/manage dietary needs using nutrition knowledge
adapt specialized diets to individual patient needs
counsel and educate patients
supervise dietary services for a facility
Chaplain/Spiritual Care Provider
Functions:
identify and respond to spiritual needs of:
patients
families
interdisciplinary team members
Potential preparation types:
clergy
pastoral care workers with graduate degrees
lay volunteers
Assistive Personnel (AP)
Role:
support nurses in providing direct patient care
Titles may include (state-defined):
certified nursing assistants
orderlies
attendants
technicians
Scope governance:
defined by state boards of nursing
Trends and Issues in Health Care Delivery
Focus on Preventive Care
Rising health awareness and desire for involvement in care influences delivery
Preventive program examples:
stress management programs
nutrition awareness
exercise/fitness programs
anti-smoking campaigns
anti-drug campaigns
Additional public health measures identified as important to health:
seat belt legislation
automobile and airplane safety promotion
smog control
gun control
hazardous waste elimination
Context issues noted:
escalating violence
increasing opioid misuse deaths
Box 11-4 — Trends to Watch in Health Care Delivery
Changing demographics
Increasing diversity
Technology explosion
Globalization of economy and society
Educated and engaged consumers
Increasing complexity of patient care
Costs of health care
Effect of health policy and regulation
Shortages of key health care professionals and educators
Knowledgeable and Engaged Consumers
Consumer definition:
person who uses a commodity or service
Health care consumers (patients/clients) described as increasingly:
knowledgeable about health
preferring control and decision-making in care
active participants in planning/implementation
Nursing practice requirement:
partnership-building skills with patients and families
Information access driver:
widespread online health information availability
Safety/quality risk:
patients may learn incorrect information online
Nursing responsibility:
assess what patients believe/know about their condition
correct false/inappropriate information respectfully
Consumer concerns commonly include:
access to services
cost
quality of care received
Consumer influence on systems:
involvement in facility administration
development of standards for care
development of patient rights
development of cost-containment measures
Patient engagement benchmark requirement (CMS, as stated):
more than 50% of patients must receive timely access to health information, including:
diagnostic test results
medication lists
clinical summary of office visit
timeline: within 1 business day
Relationship statement:
respectful, trusting, compassionate relationships remain the most effective strategy to achieve engagement goals
Mobile Health
Patient use trends:
health apps, smartphones, tablets
Patient capabilities via technology:
access medical records online
schedule appointments
communicate with caregivers online
Clinician tools:
tablets for EHR access
drug reference materials
other clinical data access
Chronic illness monitoring examples via devices/apps:
weight
blood pressure
blood glucose
Telehealth trend:
increased telehealth medical visits during 2020 pandemic
expected continuation
Nursing technology use example:
filming procedure teaching moments (e.g., dressing a port) and sharing with patients/family caregivers electronically
Informatics cross-reference noted in text (no additional content added)
Racial Justice and Equity
2020 identified as a period of:
pandemic impact
racial violence attention
increased visibility of Black Lives Matter movement
Health care team expectations described:
recurrent calls for team members to become antiracist
movement toward zero tolerance for racism
Professional actions described:
awareness of personal beliefs/attitudes linked to unconscious bias/prejudice
readiness to speak out against institutional structures perpetuating inequity/inequality
“remaining silent is no longer an option” (concept captured without quoting)
Health Care: A Right, a Privilege, or an Obligation of a Moral Society?
Two major factors influencing health care provision:
ability to pay
location of facilities
Groups identified as often having inadequate access:
poor or uninsured people
minorities
rural residents
older adults
Persistent system issue:
inadequate health insurance coverage for many people
Policy environment note:
ongoing uncertainty about effects of political administration on reform
Ethical dilemma question set presented in text (for awareness in nursing ethics context):
equitable care for people with risky behaviors vs healthy behaviors
responsibility for funding care for unemployed/homeless
fairness in organ allocation influenced by media access
higher premiums/taxes to cover intensive care for overdose
access for undocumented workers vs citizens
criteria for allocating COVID-19 vaccines
vaccination status as a criterion for scarce critical care resources
decision-making authority and criteria for scarce transplant organs
Ethics reference invoked by text:
Code of Ethics for Nurses and ANA reform resources as guides (no interpretation added)
Nurses’ Role in Health Care Reform
Health system change creates opportunities for nurses to shape future care
Reform priorities emphasized:
improved access to care
improved quality of care
cost control/containment
Drivers/challenges identified:
increasing older adult population
changing consumer expectations
expanding technology
increasing disparities
emphasis on quality and safety
National reform goals stated:
cost containment
improved access
increased quality for all citizens
Nursing role in reform described as:
stronger advocacy voice (protesting problems, proposing solutions)
increased education progression:
APRNs
DNPs
PhDs
increased primary care provision to underserved/neglected populations:
older adults
women
infants
people living in poverty
rural populations
Leadership/decision-making participation:
nurses seated at decision tables for design, delivery, financing, and evaluation of care
Practice focus emphasized:
holistic care supporting health promotion and disease prevention
Ongoing societal issue:
continued significance of who receives care and who pays for care
Chapter 11 — Full Key Takeaways
Most health care in the United States is delivered outside of hospitals, driven by shorter hospital stays, cost containment, and emphasis on prevention.
Hospitals primarily provide acute care, while nurses must prioritize discharge planning, education, and care transitions due to reduced length of stay.
Health care settings vary widely and include:
hospitals
primary care centers
ambulatory care clinics
home health
extended-care services
specialized care centers
public and voluntary facilities
Nurses practice across multiple settings, requiring flexibility, strong assessment skills, and clear understanding of scope of practice in each environment.
Hospitals
Community hospitals are classified by:
ownership (public vs private)
profit status (for-profit vs nonprofit)
service type (general vs specialty)
Hospital services may include:
emergency care
inpatient care
surgery
diagnostics
intensive care
obstetrics
palliative care
Hospitals provide both inpatient and outpatient services, including short-stay and same-day care.
Nurses in hospitals serve in multiple roles:
direct care provider
care coordinator
educator
administrator
advanced practice provider
Magnet recognition reflects nursing excellence, quality patient care, and innovation.
Primary, Ambulatory, and Home-Based Care
Primary care centers deliver:
health maintenance
prevention
management of minor acute and chronic conditions
APRNs may:
practice independently or collaboratively
serve as primary care providers depending on state law
Ambulatory care centers:
provide outpatient services
improve access through walk-in and extended hours
include urgent care and same-day surgery centers
Home health care supports:
early hospital discharge
aging populations
chronic illness management
Nurses in home health:
assess patients
administer medications
teach and support caregivers
collaborate with interprofessional team members
Extended-Care Services
Extended-care services support individuals with:
chronic illness
disability
long-term functional limitations
Care may occur in:
assisted-living facilities
long-term care facilities
rehabilitation centers
transitional/subacute care
Most extended care is provided by family caregivers, creating significant physical and financial strain.
Long-term care emphasizes:
maintaining function
promoting independence
improving quality of life
Skilled nursing care must be available at all times and delivered by or under supervision of licensed nurses.
Specialized Care Centers
Specialized care centers focus on specific populations or needs, including:
daycare centers
mental health and crisis centers
rural health centers
schools
industrial clinics
homeless shelters
rehabilitation centers
parish nursing programs
Nurses in these settings provide:
screening
education
medication administration
referrals
coordination of community resources
Rural health care often relies on APRNs and telehealth to address provider shortages.
Care for the Seriously Ill and Dying
End-of-life–related services include:
respite care
hospice care
palliative care
Hospice care:
is for patients with a life expectancy of 6 months or less
focuses on comfort, dignity, and quality of life
is commonly funded through Medicare
Palliative care:
is not limited to end of life
may occur alongside curative treatment
focuses on symptom management and quality of life
Nurses play a central role in:
pain and symptom control
family education
emotional and spiritual support
bereavement care
Health Care Facilities
Voluntary facilities:
are nonprofit
are funded by donations and grants
provide community-based services and support groups
Government facilities include:
Public Health Service (PHS)
public health departments
Public health facilities focus on:
disease prevention
health promotion
population-level care
Nurses in public health:
provide prenatal and well-child care
conduct screenings
perform outreach
address social determinants of health
Interprofessional Health Care Team
Effective health care delivery requires collaboration among:
physicians
APRNs
nurses
PAs
therapists
pharmacists
social workers
dietitians
chaplains
assistive personnel
Nurses coordinate care and ensure:
communication among team members
safe delegation
continuity of care
Nurses are not automatically required to follow PA orders unless state law and institutional policy allow.
Trends and Issues in Health Care Delivery
Major trends influencing health care:
focus on preventive care
rising consumer engagement
technological expansion
telehealth growth
increasing care complexity
workforce shortages
Health care consumers:
expect access to information
participate in decision-making
question costs and quality
Technology has expanded:
access to health data
remote monitoring
patient–provider communication
Equity, Ethics, and Health Care Reform
Persistent health disparities exist based on:
income
insurance status
race/ethnicity
geography
Nurses must:
recognize bias and inequity
advocate for fair access to care
uphold ethical principles
Health care reform priorities include:
cost containment
improved access
improved quality
Nurses are increasingly:
advancing education
serving in leadership roles
shaping policy and system design
Nursing’s holistic approach positions nurses as key leaders in reform efforts.