Health Care Delivery System

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Chapter

Health Care
Delivery
Systems
Kozier & Erb's Fundamentals of Nursing, 8e
Berman, Snyder, Kozier, Erb
Copyright 2008 by Pearson Education, Inc.

6

Question 1
Which of the following is an example of a
primary prevention activity?
1.
2.
3.
4.
5.

Antibiotic treatment of a suspected urinary tract
infection.
Occupational therapy to assist a client in adapting
his or her home environment following a stroke.
Nutrition counseling for young adults with a strong
family.
History of high cholesterol.
Removal of tonsils for a client with recurrent
tonsillitis.

Copyright 2008 by Pearson Education, Inc.

Rationales 1
1. Antibiotic therapy is secondary
prevention.
2. Rehabilitation efforts following an
illness are considered tertiary
prevention.
3. Correct. Actions such as diet
modification that help to prevent an
illness or detect it in its early stages
are primary prevention.
4. Surgery is secondary prevention.
Copyright 2008 by Pearson Education, Inc.

Question 2
Which of the following statements is true
regarding types of health care agencies?
1.
2.
3.
4.

Hospitals provide only acute, inpatient services.
Public health agencies are funded by
governments to investigate and provide health
programs.
Surgery can only be performed inside a hospital
setting.
Skilled nursing, extended care, and long-term
care facilities provide care for the elderly whose
insurance no longer covers hospital stays.
Copyright 2008 by Pearson Education, Inc.

Rationales 2
1.

Hospitals may provide a variety of wellness and
clinic programs in addition to inpatient services.
2. Correct. City, county, state, or federal
government funds pay for health department
and agency activities aimed at the global health
of the community.
3. Surgery may be performed in outpatient surgery
centers and physicians’ offices in addition to
within hospitals.
4. Skilled nursing, extended care, and long-term
care facilities provide care to persons of all ages
who require rehabilitation or subacute care. This
is not necessarily related to insurance coverage
for hospital stays.
Copyright 2008 by Pearson Education, Inc.

Question 3
In most cases, clients must have a
primary care provider in order to receive
health insurance benefits. If a client is in
need of a primary care provider, it is
most appropriate for the nurse to
recommend which of the following?
1.
2.
3.
4.

Family practice physician
Physical therapist
Case manager/discharge planner
Pharmacist
Copyright 2008 by Pearson Education, Inc.

Rationales 3
1. Correct. Primary care providers are
limited to generalist physicians and
advanced practice nurses. In some cases
a gynecologist may qualify as a primary
care provider and in other cases not.
2. Physical therapists do not have a scope of
practice broad enough to serve as primary
care providers.
3. Pharmacists are not responsible for
providing direct client care.
4. Case managers/discharge planners are not
responsible for providing direct client care.
Copyright 2008 by Pearson Education, Inc.

Question 4
The most significant method for reducing the
ongoing increase in the cost of health care in
the United States includes controlling which of
the following?
1.
2.
3.
4.

Number of children according to the family's
income.
Numbers of uninsured and underinsured
persons.
Number of physicians and nurses nationwide.
Competition among drug and medical
equipment manufacturers.
Copyright 2008 by Pearson Education, Inc.

Rationales 4
1.

2.

3.
4.

The number of children is increasing, but in the United
States and Canada this is a nonmodifiable factor. Also,
the majority of health care costs are incurred by adults
and elders who tend to have multiple and chronic health
conditions.
Correct. When people have inadequate insurance for
health costs, they tend to avoid early and preventive
care. This results in eventual use of much more costly
resources such as emergency rooms. Methods to provide
minimum levels of insurance coverage have been
successful in other countries.
There is currently a significant shortage of nurses and
maldistribution of physicians so reducing their numbers
would only worsen the problem.
Competition among manufacturers is more likely to cause
costs to fall than to rise.
Copyright 2008 by Pearson Education, Inc.

Question 5
A client is seeking to control health care costs
for both preventive and illness care. Although
no system guarantees exact out-of-pocket
expenditures, the most prepaid and predictable
client contribution would be seen with:
1.
2.
3.
4.

Medicare.
An individual fee-for-service insurance.
A preferred provider organization (PPO).
A health maintenance organization (HMO).

Copyright 2008 by Pearson Education, Inc.

Rationales 5
1.

Medicare covers a minimal number of preventive
and outpatient services so the cost cannot be
anticipated.
2. Individual fee-for-service insurance is perhaps the
most costly to the client, with potentially large
differences between the amount of coverage the
insurance company pays and the provider’s
charges.
3. Correct. A health maintenance organization
involves a set monthly membership fee and
predictable visit or deductible costs.
4. PPOs are less costly than fee-for-service but more
expensive than HMOs.
Copyright 2008 by Pearson Education, Inc.

Types of Health Care
Services
• Primary prevention
– Health promotion
– Illness prevention

• Secondary prevention
– Diagnosis
– Early detection
– Treatment

Copyright 2008 by Pearson Education, Inc.

Types of Health Care
Services
• Tertiary prevention
– Rehabilitation
– Health restoration
– Palliative care

Copyright 2008 by Pearson Education, Inc.

Health Care Agencies
• Government agencies
– Public health services

• Physicians’ offices
– Primary care
– Routine health screening
– Diagnosis and treatment

Copyright 2008 by Pearson Education, Inc.

Health Care Agencies

Copyright 2008 by Pearson Education, Inc.

Health Care Agencies
• Government agencies
– Public health services

• Physicians’ offices
– Primary care
– Routine health screening
– Diagnosis and treatment

Copyright 2008 by Pearson Education, Inc.

Health Care Agencies
• Ambulatory care centers
– Diagnostic treatment facilities
– Minor surgery

• Occupational health clinics
– Run by companies for employees
– Health promotion activities

Copyright 2008 by Pearson Education, Inc.

Health Care Agencies
• Hospitals





Acute inpatient services
Outpatient and ambulatory care
Emergency department
Hospice care

• Subacute care
– Variation of inpatient care
– Technically complex treatments
Copyright 2008 by Pearson Education, Inc.

Health Care Agencies
• Extended care facilities (formerly
called nursing homes)





Independent living
Assisted, skilled, extended care facilities
Rehabilitation
Custodial care

• Retirement and assisted-living centers
– For clients unable to stay at home, but do
not require hospital or nursing home
Copyright 2008 by Pearson Education, Inc.

Health Care Agencies
• Rehabilitation centers
– Restore or recuperate health
– Drug and alcohol

• Home health care agencies
– Education to clients and families
– Care to acute, chronic, or terminally ill

• Rural care hospitals
– Federal funding
– Services for rural residents
Copyright 2008 by Pearson Education, Inc.

Health Care Agencies
• Day-care centers
– Infants or children
– Adults that cannot be left at home

• Hospice services
– Care for dying in home or facility
– Improve or maintain quality of life until
death

Copyright 2008 by Pearson Education, Inc.

Health Care Agencies
• Crisis centers
– Emergency services for life crises
– Counseling and support

• Mutual support or self-help groups
– Health problems
– Life crises

Copyright 2008 by Pearson Education, Inc.

Health Care Professionals
• Nurses
• Alternative (complementary) care
providers
• Case manager
• Dentists
• Dietitians
• Nutritionists
Copyright 2008 by Pearson Education, Inc.

Health Care Professionals
RN
develops
nursing
PT designs
strengthening care plan
and balance
exercise plan
MD develops
medical care plan,
prescribes
medications and
treatments

Dietician
creates
low-salt diet

73-year old
with heart
failure, short of
breath

OT designs
self-care activities
that reserve
client's energy

Case
manager
Resp Therapist
communicates
provides
care plan to
breathing
Pharmacist
family and other
treatments
supplies and providers
teaches about
medications

Copyright 2008 by Pearson Education, Inc.

Health Care Professionals
• Alternative
(complementary care
providers)
• Dentists
• Nurses
• Nutritionists
• Occupational
therapists
• Paramedics/EMTs
• Pharmacists









Physical therapists
Physicians
Physician assistants
Podiatrists
Respiratory therapists
Social workers
Spiritual support
personnel
• Unlicensed assistive
personnel (UAPs)
Copyright 2008 by Pearson Education, Inc.

Factors that Affect Health Care
Delivery










Increasing number of elderly
Advances in technology
Economics
Women’s health issues
Uneven distribution of services
Access to health insurance
Homeless and the poor
HIPAA
Demographic changes
Copyright 2008 by Pearson Education, Inc.

Number of Nurses per 100,000
Population Map

Copyright 2008 by Pearson Education, Inc.

Medicare
• For adults over 65
• Part A provides hospitalization, home
care, hospice
• Part B provides partial outpatient and
physician services (voluntary)
• Part D prescription plan (voluntary)
• Does not cover dental, eyeglasses,
hearing aids, etc.
Copyright 2008 by Pearson Education, Inc.

Medicaid
• Financial assistance
• Each state is distinct

Copyright 2008 by Pearson Education, Inc.

Supplemental Security
Income
• Benefits for people with disabilities
• For those not eligible for Social
Security

Copyright 2008 by Pearson Education, Inc.

State Children’s Health
Insurance Program (SCHIP)
• Insurance coverage for poor and
working class children
• Includes primary care, prescriptions,
hospitalization

Copyright 2008 by Pearson Education, Inc.

Prospective Payment
System
• Limits amount paid to hospitals that
are reimbursed by Medicare

Copyright 2008 by Pearson Education, Inc.

Private Insurance Plans
• Not-for-profit and For-profit
• Most often pay 80% of costs

Copyright 2008 by Pearson Education, Inc.

Health Care Group Plans
• Provide blanket medical service in
exchange for monthly payment






Health Maintenance Organization (HMO)
Preferred Provider Organization (PPO)
Preferred Provider Arrangements (PPA)
Independent Practice Associations (IPA)
Physician/Hospital Organizations (PHO)

Copyright 2008 by Pearson Education, Inc.

Post Test
• Use your clickers to complete the
following post test.

Copyright 2008 by Pearson Education, Inc.

Question 1
Which of the following is an example of a
primary prevention activity?
1.
2.
3.
4.
5.

Antibiotic treatment of a suspected urinary tract
infection.
Occupational therapy to assist a client in adapting
his or her home environment following a stroke.
Nutrition counseling for young adults with a strong
family.
History of high cholesterol.
Removal of tonsils for a client with recurrent
tonsillitis.

Copyright 2008 by Pearson Education, Inc.

Rationales 1
1. Antibiotic therapy is secondary
prevention.
2. Rehabilitation efforts following an
illness are considered tertiary
prevention.
3. Correct. Actions such as diet
modification that help to prevent an
illness or detect it in its early stages
are primary prevention.
4. Surgery is secondary prevention.
Copyright 2008 by Pearson Education, Inc.

Question 2
Which of the following statements is true
regarding types of health care agencies?
1.
2.
3.
4.

Hospitals provide only acute, inpatient services.
Public health agencies are funded by
governments to investigate and provide health
programs.
Surgery can only be performed inside a hospital
setting.
Skilled nursing, extended care, and long-term
care facilities provide care for the elderly whose
insurance no longer covers hospital stays.
Copyright 2008 by Pearson Education, Inc.

Rationales 2
1.

Hospitals may provide a variety of wellness and
clinic programs in addition to inpatient services.
2. Correct. City, county, state, or federal
government funds pay for health department
and agency activities aimed at the global health
of the community.
3. Surgery may be performed in outpatient surgery
centers and physicians’ offices in addition to
within hospitals.
4. Skilled nursing, extended care, and long-term
care facilities provide care to persons of all ages
who require rehabilitation or subacute care. This
is not necessarily related to insurance coverage
for hospital stays.
Copyright 2008 by Pearson Education, Inc.

Question 3
In most cases, clients must have a
primary care provider in order to receive
health insurance benefits. If a client is in
need of a primary care provider, it is
most appropriate for the nurse to
recommend which of the following?
1.
2.
3.
4.

Family practice physician
Physical therapist
Case manager/discharge planner
Pharmacist
Copyright 2008 by Pearson Education, Inc.

Rationales 3
1. Correct. Primary care providers are
limited to generalist physicians and
advanced practice nurses. In some cases
a gynecologist may qualify as a primary
care provider and in other cases not.
2. Physical therapists do not have a scope of
practice broad enough to serve as primary
care providers.
3. Pharmacists are not responsible for
providing direct client care.
4. Case managers/discharge planners are not
responsible for providing direct client care.
Copyright 2008 by Pearson Education, Inc.

Question 4
The most significant method for reducing the
ongoing increase in the cost of health care in
the United States includes controlling which of
the following?
1.
2.
3.
4.

Number of children according to the family's
income.
Numbers of uninsured and underinsured
persons.
Number of physicians and nurses nationwide.
Competition among drug and medical
equipment manufacturers.
Copyright 2008 by Pearson Education, Inc.

Rationales 4
1.

2.

3.
4.

The number of children is increasing, but in the United
States and Canada this is a nonmodifiable factor. Also,
the majority of health care costs are incurred by adults
and elders who tend to have multiple and chronic health
conditions.
Correct. When people have inadequate insurance for
health costs, they tend to avoid early and preventive
care. This results in eventual use of much more costly
resources such as emergency rooms. Methods to provide
minimum levels of insurance coverage have been
successful in other countries.
There is currently a significant shortage of nurses and
maldistribution of physicians so reducing their numbers
would only worsen the problem.
Competition among manufacturers is more likely to cause
costs to fall than to rise.
Copyright 2008 by Pearson Education, Inc.

Question 5
A client is seeking to control health care costs
for both preventive and illness care. Although
no system guarantees exact out-of-pocket
expenditures, the most prepaid and predictable
client contribution would be seen with:
1.
2.
3.
4.

Medicare.
An individual fee-for-service insurance.
A preferred provider organization (PPO).
A health maintenance organization (HMO).

Copyright 2008 by Pearson Education, Inc.

Resources
• Audio Glossary
• Case Management Resource Guide
Searchable database of over 120,000 specialty health care
services, facilities, businesses, and organizations
• Critical Pathways in Home Care
This site defines critical pathways and their use in home care.
• Medicare: Alternatives to Nursing Home Care
The Official U.S. Government site for people with Medicare offers
information on alternatives to nursing home care.
• Medicare: Nursing Homes Overview
The Official U.S. Government site for people with Medicare gives
an overview of nursing homes.
• Centers for Medicare & Medicaid Services
Information and press releases on topics pertaining to Medicaid
and Medicare
Copyright 2008 by Pearson Education, Inc.

Resources
• Healthy People 2010
This site contains the Healthy People 2010 documents
• The National Academies News
U.S. Health Care Delivery System Needs Major Overhaul To Improve
Quality and Safety
• Harvard Medical School Department of Health Care Policy
The Department of Health Care Policy is to serve the nation as a
leading source for scientific knowledge about our health care system.
• 21st Century Advances
The Office on Women's Health in the U.S. Department of Health and
Human Services
• Council on Health Care Economics and Policy
This site provides information on health care policy research and
information from key experts in health care economics.

Copyright 2008 by Pearson Education, Inc.

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