Challenges to health care
Reducing health care costs while maintaining high-quality care for patients
Improving access and coverage for more people
Encouraging healthy behaviors- removal or waste
Earlier hospital discharges result in more patients needing nursing homes or home care.
Emphasis on population wellness
- Health Services Pyramid- bottom to top:
population based health care services
clinical preventive services
Primary health care
secondary health care
tertiary health care
- Managing health instead of illness
- Emphasis on wellness
- Injury prevention programs
National priorities
Patient and family engagement
Population health
Safety/eliminating errors as possible
Care coordination
Palliative care for advanced illnesses
Overuse/reducing waste
Institute of medicine
- Nurses need to be transformed by:
1. Practicing to the full extent of their education and training
2. Achieving higher levels of education and training through an improved education
system that provides seamless progression
3. Becoming full partners, with physicians and other providers, in redesigning the health
care system
4. Improving data collection and the information infrastructure for effective workforce
planning and policy making
Major categories of health care services
Health Promotion & Maintenance
Illness Prevention
Diagnosis & Treatment
Rehabilitation & Long-Term Care
Preventive- primary care
- Focuses on improved health outcomes for an entire population
- Requires collaboration among health professionals, health care leaders, and
community members
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- Reduces incidence of disease
- Minimizes complications
- Reduces the need for more expensive resources
- Occurs in home, work, and community settings
- lowers costs
Secondary and tertiary care
- Also called acute care
- Focus: Diagnosis and treatment of disease
- Disease management is the most common and expensive service of the health care
delivery system.
- 20% require 80% of health care spending.
- Fastest growing age group of uninsured?
- settings: ICU (expensive), psych care, hospitals, rural hospitals
- discharge planning is nurses role
Restorative care
- Serves patients recovering from an acute or chronic illness/disability
- Helps individuals regain maximal function and enhance quality of life
- Promotes patient independence and self-care abilities
- Requires multidisciplinary approach
- Settings: home care, rehab, extended care
Home care
- Provision of medically related professional and paraprofessional services and
equipment to patients and families in their homes for health maintenance, education,
illness prevention, diagnosis and treatment of disease, palliation, and rehabilitation
- Involves coordination of services
- Focuses on patient and family independence
- Usually reimbursed by government (such as Medicare and Medicaid in the United
States), private insurance, and private pay sources
Rehabilitation
- Focus: To restore patients to their fullest physical, mental, social, vocational, and
economic potential
- Includes physical, occupational, and speech therapy, as well as social services
- Occurs in many health care settings, both inpatient and outpatient
Extended care
- Extended care facility: Provides intermediate medical, nursing, or custodial care for
patients recovering from acute illness or disabilities
- Skilled nursing facility (intermediate care): Provides care for patients until they can
return to their community or residential care location
Continuing care
- assisted living, respite care, adult day care centers, hospice
- For people who are disabled, functionally dependent, or suffering a terminal disease
Nursing centers
- Provide 24-hour intermediate and custodial care
Nursing, rehabilitation, diet, social, recreational, and religious services
- Residents of any age with chronic or debilitating illness
- Regulated by standards: Omnibus Budget Reconciliation Act of 1987
- Interdisciplinary functional assessment is the focus of clinical practice: MDS, RAIs
Assisted living
- long term care setting with home environment and greater patient autonomy
- provides laundry rooms, assistance with meals, personal care, housekeeping, 24 hour
over site
- residents can live in their own units
Respite care
- The service provides short-term relief or "time off" for persons providing home care to
an ill, disabled, or frail older adult.
- Settings include home, day care, or health care institution with overnight care.
- Trained volunteers allow family caregivers to leave the home for errands or social time.
Classification of health care agencies
- Governmental or voluntary (private)
- Not-for-profit or for-profit
- Level of services they provide
Governmental or federal agencies
- Focus on health of all U.S. citizens
- Promote & conduct research
- Provide funding to train
- Assist communities in planning services
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Organizational structure of agency
Board of Directors
Chief Executive Officer
Medical Staff: Chief of Staff
Nursing Staff: Chief Nurse Executive
Health care accreditation
- To demonstrate quality and safety
- To evaluate performance, identify problems, and develop solutions
- Accreditation earned by the entire organization
- Specific programs or services within an organization earn certifications.
- The Joint Commission and others
Maintaining quality in agencies
- Accreditation of health care agencies - Through one of two accrediting bodies
approved by the Centers for Medicare and Medicaid Services (CMS)
- The Joint Commission
- Nonprofit; serving as the nation's predominant standard-setting and accrediting body in
U.S. health care
- Healthcare Facilities Accreditation Program (HFAP)
- Continuous quality improvement/total quality management: An internal strategy for
organizations to work toward improvement in patient outcomes
- Focus on establishing procedures for ensuring high-quality patient care
Health care disparities
Ethnic or racial disparities -- Education level
Gender -- Disability
Age -- Sexual orientation
Income -- Place of residence
Health care team
- Health personnel from different disciplines who coordinate their skills to assist clients
and their support persons
- Goal: Restore health, Promote wellness
Physicians
Physician assistants
Patient care technicians
Licensed practical nurses/licensed vocational nurses
Dietitians
Pharmacists
Technologists
Respiratory therapist
Social workers
Physical therapists
Occupational therapists
Administrative support personnel
Nurses role
Provider of care: Provide direct, hands-on care in all health care agencies and settings;
they have an active role in:
Illness prevention
Health promotion
Health maintenance
Educator
Counselor
Manager
Researcher
Collaborator
Patient advocate
Care delivery models
- Detail how task assignments, responsibility, and authority are structured to accomplish
patient care
- Describe which health care worker is going to perform what tasks, who is responsible,
and who has the authority to make decisions
- Basic premise is that the number and type of caregivers are closely matched to patient
care needs in a cost-effective manner
Patient classification system
- Categorize patients according to care needs (acuity level) how much nursing care a
patient is going to need, comparative to other patients
- Higher acuity levels mean that nursing care needs are more intense
- Important research is validating the contribution and value of registered nurses (RNs)
to improved patient outcomes and prevention of premature mortality
- Primary considerations for staffing a nursing unit:
Number of patients
Intensity of care required
Staff experience and preparation
Geography of the environment
Available technology
Staffing and patient needs
-ANA recommends that classification systems should consider patients':
Age and functional ability
Communication skills
Cultural and linguistic diversities
Severity and urgency of the admitting condition
Scheduled procedures
Ability to meet health care requisites
Availability of social supports
Other specific needs as identified by the patient and the RN
Staffing and patient needs continued
- Staff members must have the educational preparation, skill, and experience necessary
to meet patient care needs
- Concerns about inadequate numbers of appropriately skilled and experienced staff
should be addressed with executive level managers
Staffing and organizational needs
- Organizational needs affected by staffing include: Financial resources, Licensing
regulations and accreditation standards, Customer satisfaction
- Nurse manager is accountable for budgetary guidelines for RNs are the most
expensive staff; thus ratios for RNs to other types of care providers may be established
- Licensing and accreditation agencies do not impose mandatory staffing ratio but do
look for evidence that patients are adequately cared for
- Customer satisfaction is critical to an organization's success
- A customer's personal interaction with employees is key to satisfaction
Financing health care
- Supply and demand: Suppliers provide goods and services; consumers demand and
use them. When demand exceeds supply, prices rise. When supply exceeds demand,
prices fall.
- Principles of a Free-market Economy: Consumption of any good or service is
determined by an individual's ability to pay.
- In a pure free-market economy, a portion of the population would be denied health
care if they were unable to pay.
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Financing health care continued
- Economics of nursing care: Nursing care accounts for 20% to 28% of the cost of
hospitalization for most patient groups.
- Determining the cost of nursing services and developing standardized reimbursements
based on costs would enhance: The ability of nurse managers to control resources,The
ability to negotiate for a fair share of hospital financial resources
- Costing nursing services remains an inexact science.
History of health care finance
- Before 1940, more than 90% of Americans paid directly from their own pockets or
depended on charity care.
- After WWII, most industrialized countries began publicly financed health care systems
- United States did not do this but continued private-pay.
- United States health care costs have skyrocketed.
- Providers and suppliers have used lucrative loopholes to drive costs up.
- Population growth and increased proportion of elderly and chronically ill have further
driven up costs and complicated efforts to find solutions.
Current methods for payment
- Private insurance: Voluntary insurance; insurance premiums are paid either by insured
individuals or their employers or are shared between individuals and employers
- Medicare: A nationwide federal health insurance program established in 1965 for
people ages 65 and over, regardless of income
- Also covers certain groups of disabled people
Contain Parts A, B, C, D
- Medicaid: Group of jointly funded federal-state programs for low-income, elderly, blind,
and disabled individuals, established in 1965: People must meet eligibility requirements.
- Personal payment: Out-of-pocket payment, which only the very wealthy can afford:
Least frequently used method for financing health care
- Workers' Compensation: Covers workers who are injured on the job: Program varies
from state to state, Covers treatment for injuries during time worker is absent from work
for injury-related causes
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