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Chapter 3
The Healthcare Delivery System
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Healthcare Trends and Challenges in the
21st Century
• There is an emphasis on wellness and individuals
assuming more responsibility for their own health.
• Technology continues to influence healthcare.
• The rising costs of healthcare are to be met by
preventive care.
• Health education is an important aspect of healthcare.
• Health maintenance organizations (HMOs) provide
managed care; they emphasize disease prevention and
health promotion.
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The Impact of the Changes on Nurses,
Healthcare Practitioners, and Clients
• Healthcare may involve discussion among the healthcare
practitioner, an insurance provider, and the client.
• With the increasing challenges, it is not uncommon for
unlicensed assistive personnel (UAPs) to be hired to
administer nursing care.
• As a result of financial constraints and the influence of
managed care plans, clients may even be forced to have
treatment outside a hospital.
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Acute Care and Extended Care Facilities
Acute Care Facilities
Extended Care Facilities
Clients with serious
conditions or high level of
acuity are admitted for a
short period.
Clients discharged from
acute care facilities may be
admitted for a longer period.
Include:
Include:
•Acute care hospitals
•Intensive care units
•Subacute care facilities
•Skilled nursing facilities
•Intermediate care facilities
•Inpatient rehabilitation
centers
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Healthcare Settings and Services
• Specialized Hospitals
– These facilities admit only one type of client for
specific conditions.
• Home Healthcare
– Service provided by an acute care facility or an
agency that specializes in home healthcare.
• Hospice
– Specializes in the care of the terminally ill
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Healthcare Settings and Services (cont’d)
• Respite Care
– Part-time supervision of clients who have chronic
conditions
• Telehealth
– Ability to access a nurse or physician via telephone
or computer audio/video link
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Question
Is the following statement true or false?
Extended care facilities include intensive care units for the
critically ill.
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Answer
False
Clients who are admitted to the intensive care unit meet
the minimal level or need for healthcare services known as
acuity and are thus admitted to acute care facilities, not
extended care facilities.
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Community Health Services
• Public health service
– Immunizations, well-baby checks, and treatment for
specific diseases
• Community health clinics
– Low-cost healthcare services to the public
• Independent living facilities
– Stable, home-like environment for mentally
challenged individuals
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School Nurse
• Cares for ill children
• Provides intensive nursing care for the physically
challenged
• Promotes preventive care by regular assessments,
teaching, and screening for common disorders
• Supervises administration of immunizations and
medications
• Provides teaching and health counseling
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Industrial Nurse
• Promotes health
• Teaches prevention of accidents
• Serves as a liaison between the industry and the
Occupational Safety and Health Administration (OSHA)
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Functions of The Joint Commission
• The Joint Commission accredits a hospital or other
healthcare facility.
• It has established rigid standards for an ongoing quality
assurance program in acute care and extended care
facilities.
• It requires objective and systematic monitoring and
evaluation of the quality and appropriateness of client
care.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Relation of The Joint Commission’s
Functions to Nursing
• The Joint Commission stresses the importance of quality
assurance. As a result, facilities and agencies have
contiguous quality improvement (CQI) committees that
monitor the quality of ongoing care.
• The process of care relates to how care is given. The
outcome, which is equally important, relates to the
result, which is also known as outcome-based care.
Thus, nurse accountability, which involves the delivery
and accurate documentation of quality care, is vital.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Quality Assurance in Healthcare Facilities
• Quality assurance focus on delivery of care. The
standards of quality include:
– Standards of nursing practice
– Standards of client/patient care
– Standards of performance
• The nursing audit committee or CQI committee evaluates
care given to clients.
• Peer review allows nurses to constructively critique each
other.
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Roles of the Client Representative and
Advocate or Ombudsperson
• To act as a consumer advocate and assist the client and
family by resolving concerns or problems
• To focus on client care, needs, and concerns, and listen
and answer questions
• To help clients and their families find needed services
like housing, child care, etc
• During hospitalization, clients have the right to contact
their representatives if they have a concern. Each
individual receives a copy of the Patient’s Bill of Rights.
The nursing case manager has overall responsibility for
the client’s care, and the advocate assists as needed.
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Question
Is the following statement true or false?
A client representative can also be called a consumer
advocate.
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Answer
True
Client representatives act as consumer advocates and
assist the client and family by resolving concerns or
problems.
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Hospital Organization and Ownership
• Numerous trained individuals work together in organized
units
• Government ownership
• Private ownership
– Proprietary, investor-owned, or for-profit
– Not-for-profit
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Financing Healthcare
• The Health Planning and Resources Development Act of
1975 established legislation to govern the amount and
types of facilities, services, and workers needed in each
designated geographic area in the United States.
• Resources for the 21st century must include at least 24
healthcare priorities.
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Methods of Payment
• Individual Private Insurance
• Group Insurance
• Fee for Service Plans
• Health Maintenance Organizations
• Preferred Provider Organizations (PPOs)
• Point of Service Plans (POS)
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Methods of Payment (cont’d)
• Medicare
• Medicaid
• Prospective Payment
• Diagnosis-Related Groups (DRGs)
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Question
Which of the following is not a feature of HMOs?
a. Each plan has a predetermined co-pay.
b. Members can use any physician they choose, and the
HMO will pay for this service.
c. A premium must be paid in advance to the HMO.
d. Members prepay for healthcare services generally
through payroll deductions, etc.
e. Most HMOs include group practice, prepayment,
prevention, and treatment.
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Answer
b. Members can use any physician they choose, and the
HMO will pay for this service.
Members must use a physician within the HMO network.
HMO members can elect to go to any physician or seek any
medical service that is not part of the HMO network.
However, the HMO will generally not pay for this service
unless it is preapproved by the administrators of the plan.
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Complementary Healthcare
• Chiropractic, Physical, and Occupational Therapy
• Holistic Healthcare
• Herbalists and Vibrational Remedies
• Acupuncture and Acupressure
• Relaxation and Imagery
• Meditation
• Therapeutic Touch
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Consumer Fraud
• As a result of misleading the public with “sure cures,” ill
people run the risk of delaying vital treatment for
diseases such as cancer and obesity until it is too late.
• The general public often cannot tell the difference
between true and false claims. As a nurse, you may
encourage clients to find out all the facts before starting
any untested healthcare measure.
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End of Presentation
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