Health Care Delivery

Core Objectives of Health Care Delivery

• System Structure Overview: Explore the overall structure and regulatory mechanisms of the health care delivery system.
• Disparities and Social Determinants: Describe health care disparities alongside the direct effects of social determinants of health (SDOH).
• Settings and Service Levels: Discuss acute, long-term, and community health care settings and their associated services.
• Interprofessional Collaboration: Discuss the specific roles of interprofessional health care team members in delivering client care.

Structure and Regulation of the Health Care Delivery System

• Affordable Care Act (ACA):
  • Focuses heavily on disease prevention.
  • Emphasizes preventative and maintenance health care to optimize long-term health outcomes.
• State Regulation:
  • Regulated at the state level by governing bodies such as the State Board of Nursing (BON).
• Accreditation:
  • Designed to maintain high-quality care and ensure patient safety across healthcare facilities.

Healthcare Quality and Accreditation Organizations

• The Joint Commission (TJC):
  • An independent, nonprofit organization dedicated to healthcare accreditation.
  • Employs experienced surveyors to evaluate clinical facilities.
  • Survey and evaluation methods:
  • Comprehensive documentation review.
  • Systematic policy review.
  • Direct stakeholder and staff interviews.
  • National Patient Safety Goals (NPSGs):
  • Standardized safety practices established to address specific health care safety concerns.
  • Sentinel Events:
  • Unanticipated patient safety events that result in patient death or severe physical/psychological harm, requiring immediate investigation and action.

• National Committee for Quality Assurance (NCQA):
  • Organization dedicated to assessing and reporting on the quality of managed care plans and health care programs.

Nursing Excellence and Credentialing Programs

• The American Nurses Credentialing Center (ANCC):
  • An organization that actively supports nurses and promotes practice excellence to directly improve client care.
  • Offers two primary recognition pathways:
  • Magnet Recognition: Recognizes healthcare organizations that demonstrate nursing excellence, administrative support, and quality patient outcomes.
  • Pathway to Excellence Program: Recognizes healthcare environments that create supportive work cultures and empower nursing staff.

Public Health Funding: Medicare vs. Medicaid

• Medicare:
  • Federal health insurance program designed for specific population groups:
  • Individuals $65$ years of age or older.
  • Individuals under $65$ years of age who have qualifying disabilities.
  • Individuals of any age diagnosed with End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS).
• Medicaid:
  • Joint federal and state program providing health coverage.
  • Eligibility requirements are primarily determined by an individual's or family's income level in relation to the federal poverty level.

Insurance Reimbursement Frameworks

• Diagnosis-Related Groups (DRG):
  • A system utilized by the Centers for Medicare and Medicaid Services (CMS) to classify hospital admissions for fixed reimbursement amounts.
• Resource Utilization Groups (RUG):
  • A system utilized primarily in long-term care settings to determine reimbursement levels based on patient resource intensity and clinical care needs.
• Management of Resources:
  • Financial and operational strategies aimed at controlling costs and ensuring effective resource allocation during client care delivery.

Social Determinants of Health (SDOH)

• Definition:
  • The conditions in the environments where people are born and where they live that affect their overall health, well-being, and quality of life.
• Five Key Domains of SDOH:
  • Economic Stability: Financial resources, income security, and employment opportunities.
  • Education Access and Quality: Access to high-quality early childhood education, literacy, and higher education attainment.
  • Social and Community Context: Community support, social cohesion, and positive social interaction.
  • Neighborhood and Built Environments: Quality of housing, neighborhood safety, access to transportation, and environmental safety.
  • Health Care Access and Quality: Health insurance coverage, primary care access, and health literacy.

Public Health Nursing Roles and Practice Settings

• Public Health Nurse Role:
  • Scope: Specifically addresses the health needs of a particular community or target population.
  • Core Functions:
  • Provide health education.
  • Monitor illness and disease prevalence within the population.
  • Improve overall community health and well-being.
• Examples of Public Health Nursing Practice Roles:
  • Occupational Health Nurse: Focuses on workplace health, worker safety, and environmental hazard mitigation.
  • School Nurse: Manages student health needs, screenings, immunizations, and chronic condition plans in educational institutions.
  • Home Health Nurse: Delivers skilled nursing care directly in client residences.
  • Infection Control Nurse: Tracks, prevents, and manages infectious disease outbreaks across healthcare or community settings.
  • Community Health Clinic Nurse: Delivers primary care, preventative interventions, and health education in outpatient community clinics.
  • Correctional Facility Nurse: Delivers clinical care and management to incarcerated individuals within correctional facilities.