Health Care Delivery Systems: Structure, Access, and the Role of Nursing

Ch 11 Health Care Delivery System

Overview of Health Care Delivery

The health care delivery system encompasses all organizations, people, and actions whose primary intent is to promote, restore, or maintain health. It includes a wide range of services, from preventive and primary care to specialized and end-of-life care.

• Safe: Minimizing risks and harm to patients.

• Effective: Providing services based on scientific knowledge.

• Efficient: Avoiding waste of resources.

• Patient-centered: Respecting and responding to individual patient preferences, needs, and values.

• Timely: Reducing waits and sometimes harmful delays.

• Equitable: Providing care that does not vary in quality because of personal characteristics.

Health Care: The Big-Picture Issues

Key Challenges in Health Care

Major issues in the health care system include access, quality and safety, and affordability. These factors influence the effectiveness and fairness of health care delivery.

• Access to health care: The ability of individuals to obtain needed health services.

• Quality and safety: Ensuring care is effective and does not cause harm.

• Affordability: The cost of health care for individuals and society.

Access to Health Care

Improving Access and the Role of Legislation

Access to health care is influenced by insurance coverage, provider availability, and legal frameworks. The Patient Protection and Affordable Care Act (PPACA) was a significant legislative effort to expand access.

• PPACA: Aimed to expand coverage, control costs, and improve the health care system.

• Health insurance marketplace: A platform for individuals to compare and purchase insurance plans.

• Shortage of providers: A challenge in many regions, especially rural areas.

• Caring for undocumented persons: Raises ethical and policy questions about universal access.

PPACA Goals

• Expand coverage to individuals up to 400% of the poverty level.

• Provide Medicaid or subsidized coverage to qualifying individuals.

• Facilitate insurance purchase through the Health Insurance Marketplace.

Quality and Safety in Health Care

Ensuring High Standards

Quality and safety are central to health care delivery. Systems are in place to monitor and improve these aspects.

• Reliable care accountability matrix: Tools to measure and ensure consistent quality.

• Pay for performance/value-based purchasing: Financial incentives for meeting quality benchmarks.

• Penalties for excess readmissions: Hospitals may face penalties if patients are readmitted too frequently.

Affordability of Health Care

Payment Systems and Cost Control

Health care affordability is shaped by how services are paid for and how costs are managed.

• Multi-payer system: Multiple sources (private, public) pay for care.

• Single-payer system: One public agency handles health care financing.

• Diagnosis-related groups (DRGs): Payment based on diagnosis, not services rendered.

• Resource utilization groups (RUGs): Used in long-term care to determine payment.

• Bundled payments: Single payment for all services related to a treatment or condition.

• Rate setting: Government or insurers set prices for services.

• Comparative effectiveness analysis: Comparing outcomes and costs of different treatments.

• Increasing patient cost sharing: Patients pay a greater share of costs (e.g., copays, deductibles).

Levels of Health Care

Hierarchy of Care

Health care is delivered at different levels, depending on the complexity of the patient's needs.

• Primary health care: First contact, treatment of common problems (e.g., family doctor).

• Secondary health care: Specialized clinical expertise (e.g., cardiologist).

• Tertiary health care: Management of rare and complex disorders (e.g., transplant centers).

Health Care Delivery Systems and Care Coordination

Types of Organizations and Coordination

Various organizations and models exist to deliver and coordinate care efficiently.

• Providers and hospitals: Core institutions in care delivery.

• Multispecialty group practices: Multiple specialists in one practice.

• Community health centers: Local centers providing primary care.

• Prepaid group practice: Members pay in advance for services (e.g., HMOs).

• HMOs (Health Maintenance Organizations): Provide comprehensive care for a fixed fee.

• PPOs (Preferred Provider Organizations): Offer more flexibility in choosing providers.

• Accountable care organizations: Groups of providers jointly responsible for patient outcomes and costs.

• Medical homes to medical neighborhoods: Coordinated, patient-centered care across settings.

• Care coordination: Organizing patient care activities to facilitate appropriate delivery of health services.

Paying for Health Care

Methods of Payment

There are several ways health care is financed in the United States.

• Out-of-pocket payment: Patients pay directly for services.

• Individual private insurance: Purchased by individuals.

• Employer-based private insurance: Provided as a benefit by employers.

• Government financing: Includes programs such as Medicare, Medicaid, CHIP, and VHA.

• Medicare: Federal program for people over 65 or with certain disabilities; uses DRGs for payment.

• Medicaid: State and federal program for low-income individuals.

• Children’s Health Insurance Program (CHIP): For children in low-income families.

• Veteran’s Health Administration (VHA): Health care for military veterans.

Strategies to Reduce Health Care Costs and Improve Delivery

Cost Reduction and Efficiency

Efforts to control costs and improve care include:

• Using quality improvement tools to reduce waste and improve safety.

• Improving transitions across care settings.

• Making medical services more efficient and less costly.

• Eliminating unnecessary costs such as fraud and abuse.

• Improving population health through preventive measures.

Health Care Settings

Where Care is Delivered

Health care is provided in a variety of settings, each serving different patient needs.

• Hospitals: Acute care for serious illnesses and injuries.

• Primary care centers: Routine health maintenance and minor illnesses.

• Ambulatory care centers and clinics: Outpatient services.

• Home health care: Care provided in the patient's home.

• Extended care services: Long-term care for chronic conditions.

• Specialized care centers and settings: Focused on specific populations or conditions.

• Health care services for the seriously ill and dying: Includes hospice and palliative care.

Role of Nurses in Health Care Settings

Nurses in Hospitals

Nurses play a variety of roles in hospitals, contributing to patient care, management, and education.

• Direct care providers: Deliver hands-on patient care.

• Manager of other health care team members: Supervise and coordinate care teams.

• Administrator: Oversee operations and policy implementation.

• Nurse practitioner: Advanced practice nurses who diagnose and treat patients.

• Clinical nurse specialist: Experts in specific areas of nursing practice.

• Patient educator: Teach patients about health and treatments.

• In-service educator: Train other health care staff.

• Researcher: Conduct studies to improve care.

Example: A nurse may manage a team of nurses and aides, provide direct care, and educate patients about post-surgical recovery.

Nurses in Primary Care Centers

Advanced practice registered nurses (APRNs), including nurse practitioners, midwives, and clinical nurse specialists, often work independently or collaboratively to provide primary care and health promotion.

• APRNs may have their own offices and clinics, depending on state regulations.

• They assess, diagnose, and treat patients, referring complex cases to physicians.

Home Health Care

Home health care is a rapidly growing sector, providing a range of services in patients' homes.

• Services include skilled nursing assessment, medication administration, patient and family education, and direct care.

• Often coordinated by community health departments, visiting nurses’ associations, or home health agencies.

• Growth driven by reimbursement systems and early hospital discharge.

Extended-Care Facilities

These facilities provide care for individuals who need assistance with daily activities or ongoing medical care.

• Include transitional subacute care, assisted-living, intermediate and long-term care, and homes for medically fragile children.

• "Aging in place" and senior retirement communities support independent living with access to care.

Specialized Care Centers and Settings

Specialized centers address specific health needs or populations.

• Daycare centers, mental health centers, rural health centers, school-based clinics, industry clinics, homeless shelters, rehabilitation centers, and parish nursing.

Health Care Services for the Seriously Ill and Dying

Specialized services provide comfort and support for patients with serious or terminal illnesses.

• Respite care: Temporary relief for caregivers.

• Hospice services: Comprehensive care for dying persons, addressing physical, psychological, social, and spiritual needs.

• Palliative care: Focuses on relief of symptoms and improving quality of life.

Example: Hospice care teams provide pain management and emotional support for terminally ill patients and their families.

Health Care Agencies

Types of Agencies

Health care agencies include both governmental and voluntary organizations.

• Voluntary agencies: Nonprofit organizations providing support and services.

• Support groups: Offer emotional and practical support for patients and families.

• Public health service: Government agencies focused on population health.

• Centers for Disease Control and Prevention (CDC): National public health institute.

• Public health facilities: Local and state health departments.

Collaborative Care: The Health Care Team

Interdisciplinary Team Members

Effective health care relies on collaboration among diverse professionals.

• Physician, physician assistant, APRN

• Nurse, assistive personnel

• Physical, occupational, speech, and respiratory therapists

• Dietitian, pharmacist

• Chaplain/spiritual care provider

Trends to Watch in Health Care Delivery

Emerging Directions

Several trends are shaping the future of health care delivery.

• Increased focus on preventive care

• More knowledgeable and engaged consumers

• Growth of mobile health technologies

• Emphasis on racial justice and equity

Ethical and Societal Issues in Health Care

Health Care as a Right, Privilege, or Obligation

There are ongoing debates about the ethical distribution of health care resources.

• Should people who engage in risky behaviors receive the same care as those who do not?

• Who should pay for care for the unemployed and homeless?

• How should scarce resources (e.g., organ transplants, COVID-19 vaccines) be allocated?

• Should undocumented workers have the same access as citizens?

• Should vaccination status affect access to critical care?

Nurses’ Role in Health Care Reform

Shaping the Future of Health Care

Nurses are increasingly influential in health care reform, advocating for holistic care and improved health outcomes.

• Nurses are taking on leadership roles in policy and practice.

• Many are advancing their education to become APRNs, DNPs, or PhDs.

• The focus remains on holistic care, health promotion, and illness prevention.

Key Terms Table

Term	Definition
Primary Health Care	First level of contact for individuals, focusing on general health needs.
Secondary Health Care	Specialized care, usually upon referral from primary care.
Tertiary Health Care	Highly specialized care for complex conditions.
DRG (Diagnosis-Related Group)	System to classify hospital cases for payment purposes.
HMO (Health Maintenance Organization)	Managed care organization providing comprehensive services for a fixed fee.
PPO (Preferred Provider Organization)	Managed care organization with more provider choice and flexibility.
APRNs	Advanced Practice Registered Nurses, including nurse practitioners and clinical nurse specialists.
Hospice	Care focused on quality of life for terminally ill patients.
Palliative Care	Care aimed at relieving symptoms and improving quality of life for serious illness.