Transcript Health Care Delivery Systems

Chapter 8
Healthcare Delivery Systems
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Frameworks for Healthcare Delivery
• Managed care systems
• Case management
• Primary healthcare
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Question
In which healthcare delivery framework is the primary
care provider referred to as the “gatekeeper” assigned to
provide care that controls the cost while maintaining the
quality of that care?
A. Managed care
B. Case management
C. Primary healthcare
D. Federally funded healthcare
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Answer
Answer: A. Managed care
Rationale:
Managed care systems provide care that controls the
cost while maintaining the quality of care.
Case management is a method of managed care in which
nurses often identify protocols and timetables for care.
Primary healthcare is essential healthcare accessible to
communities at a cost that is affordable.
Federally funded healthcare programs include Medicare
and Medicaid.
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Managed Care Systems
• Controls cost of care while maintaining quality of care
• Manager or “gatekeeper” plans and monitors the care
• Limits the choice of care providers
• Requires approval for specialty care
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Case Management
• Coordinates care
– Role of nurse is coordinator of care
• Controls costs
• Improves access to healthcare
• Uses critical pathways to identify protocols and
timetables for care
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Primary Healthcare
• Essential healthcare based on acceptable methods and
technology
• Universally accessible and affordable to individuals and
families in the community
• Brings healthcare close to where people live and work
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Healthcare Settings
• Hospitals
• Primary care centers
• Ambulatory care centers and clinics
• Home healthcare
• Long-term care facilities
• Specialized care centers and settings
• Healthcare services for caregivers and end-of-life care
• Healthcare agencies
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Question
Tell whether the following statement is true or false.
An urgent care center is a type of ambulatory care center
that provides walk-in emergency care services.
A. True
B. False
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Answer
Answer: A. True
An urgent care center is a type of ambulatory care center
that provides walk-in emergency care services.
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Hospital Settings
• Provide inpatient and outpatient care
• Vary in size and services
• Classified as profit or nonprofit, public or private
• Employ more nurses than any other facility
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Role of Nurses in Hospitals
• Direct care providers
• Manager of other members of healthcare team
• Administrator
• Nurse practitioner
• Clinical nurse specialist
• Patient educator
• In-service educator
• Researcher
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Role of Nurse in Primary Care Centers
• Make health assessments.
• Perform technical procedures.
• Assist the physician.
• Provide health education.
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Role of Nurse in Ambulatory Care Centers
• Provide technical services.
• Determine the priority of care needs.
• Provide teaching about all aspects of care.
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Long-Term Care Facilities
• Transitional subacute care
• Intermediate and long-term care
• Nursing homes
• Retirement centers
• Residential institutions for mentally or physically disabled
• “Aging in place”
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Specialized Care Centers
• Daycare centers
• Mental health centers
• Rural health centers
• Schools
• Industry
• Homeless shelters
• Rehabilitation centers
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Question
Which of the following is designed to provide palliative
and supportive care services for dying persons?
A. Respite care
B. Parish nursing
C. Voluntary agencies
D. Hospice services
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Answer
Answer: D. Hospice services
Rationale:
Hospice provides physical, psychological, social, and
spiritual care for dying persons.
Respite care is provided for caregivers of homebound ill,
disabled, or elderly patients.
Parish nursing emphasizes holistic care, health
promotion, and disease prevention activities.
Voluntary agencies are community agencies that are
often nonprofit and provide a setting for support groups.
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Home Healthcare
• Most rapidly growing area of the healthcare system
• Driven by payment system of reimbursement—early
discharge from hospitals
• Serves increasing number of older people with chronic
illnesses
• Provides for a dignified death at home
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Healthcare Agencies
• Voluntary agencies
• Parish nursing
• Government agencies
• Veterans administration and military agencies
• Public health service
• Public health agencies
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Members of the Healthcare Team
• Physician, physician assistant
• Physical, respiratory, occupational, and speech therapist
• Dietitian
• Pharmacist
• Social worker
• Unlicensed assistive personnel
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Role of the Physician
• Diagnosis of illness
• Medical or surgical treatment of illness
– Prescribing medications
– Interpreting results of lab and diagnostic tests
– Performing procedures and surgery
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Payment for Healthcare
• Federally funded programs
– Medicare—DRGs
– Medicaid
• Group plans
– Health maintenance organizations
– Preferred provider organizations
• Private insurance
• Long-term care insurance
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Question
In which of the following healthcare payment plans does
the patient have the least control of the choice of a
physician for his or her care?
A. Preferred provider organizations
B. Private insurance
C. Health maintenance organizations
D. Federally funded healthcare programs
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Answer
Answer: C. Health maintenance organizations
Rationale:
HMOs are prepaid group-managed care providers that
subscribe to receive care through affiliated providers.
Preferred provider organizations allow members to
choose an outside physician for an additional cost.
Private insurance allow members to choose their own
physicians.
Federally funded healthcare programs use a prospective
payment plan based on diagnosis-related groups.
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Healthcare Delivery Trends
• Changing demographics
• Increasing diversity
• Technology explosion
• Globalization of economy and society
• Educated consumers
• Increasing complexity of patient care
• Costs of healthcare
• Effect of health policy and regulation
• Current nursing shortage
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Healthcare Issues
• Focus on preventive care
• Knowledgeable consumers
• Cost containment
• Fragmentation of care
• Healthcare—a right or a privilege?
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Goals of Healthcare Reform
• Cost containment
• Improved access to care
• Increased quality of services for all
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Nurse’s Role in Healthcare Reform
• Stay informed about current issues and legislation.
• Write members of congress to support legislation to
improve nursing care.
• Belong to nursing organizations.
• Document the outcomes of nursing care.
• Be a leader in nursing and consumer groups.
• Advocate for the right of all to healthcare.
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