1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Chapter 1 The...

1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Chapter 1

The Health Care System


Learning Objectives

• Describe the organization of the health care system in the United States.

• Describe the focus of public health services.• Define the three levels of prevention.• Discuss financing of health care in the United States,

including Medicare and Medicaid programs.• Describe the components of the health care system that

provide outpatient and inpatient care and the types of service each provides.

• Describe the impact of cost-containment measures on the delivery of care.


Organization

• Health care system consists of patient, patient’s family, community, governmental agencies, health care providers, insurance companies

• Many health services funded by government or private agencies

• Not all U.S. citizens eligible for government funds; some unable or unwilling to obtain private insurance


Managed Care

• Provides comprehensive health care at a reasonable cost • Health maintenance organization (HMO)• Preferred provider organization (PPO)

• Managed care has stimulated increased interest in wellness and prevention, increased outpatient and home health care, and increased cost sharing


Administration

• 1953: Department of Health, Education and Welfare was established to organize the health and we

• lf are agencies of the U.S. government • 1980: Department of Health and Human Services

(DHHS) was created when education became a separate department

• Today: DHHS programs are administered by the Public Health Service and Centers for Medicare & Medicaid Services, Administration for Children and Families, and the Administration on Aging


Public Health

• Improvement of the health of communities and aggregates (collections of people) rather than the individual

• Main goals are to protect and improve the health of populations at risk in the community and to prevent disease and disability


Primary Prevention

• To improve health; prevent disease and injury • Exercise programs to increase strength and

cardiovascular fitness • Campaigns in schools to prevent children from

smoking and to educate people to wear seat belts


Secondary Prevention

• Focuses on early detection and treatment of disease to improve patient outcomes • Papanicolaou (Pap) smears and screening

mammograms


Tertiary Prevention

• To prevent disease recurrence or complications • The use of physical therapy to prevent contractures

in a stroke patient• Teaching proper diet and foot care to a person with

diabetes


Financing

• U.S. health care most expensive in the world • In 2002, $1.6 trillion (equal to 14.9% of gross

domestic product [GDP]) spent on health care, compared with 5% in 1960

• By 2013, projected total health care expenditures of $3.6 trillion, accounting for 18.4% of GDP

• Largest component of health care costs (32%) is hospital expenditures


Financing

• Many approaches to health care financing: HMOs, PPOs, and governmental agencies affect how health care is delivered

• Capitation: designed to control costs• HMOs pay physicians a fixed amount each month

for each member (patient) enrolled in the plan, regardless of whether the physician sees the patient that month


Medicare

• Medicare: health insurance program offered by the U.S. government as part of the Social Security Act

• Helps pay for health care of people ages 65 and older, those of any age with permanent kidney failure, and those younger than age 65 who qualify for Social Security disability benefits


Medicare

• Diagnosis-related groups (DRGs) • Hospitals reimbursed a flat fee for specified number

of days based on predetermined diagnosis fee schedule

• If the patient gets better faster, hospital makes money; if longer stay, hospital loses money

• Medicare prescription drug coverage• Medicare typically pays about half an individual’s

annual drug costs


Medicaid

• Government insurance program for people of very low income

• Funded by federal, state, and local taxes; administered by federal and state governments on a partnership basis

• States develop and operate Medicaid programs within federal guidelines • Benefits vary from state to state


Medicaid

• Benefits provided for needy, low-income disabled individuals younger than age 65 and their dependent children

• Individuals older than age 65 who are below a specified income level may also receive benefits, including services that Medicare does not cover


Physicians Offices

• Physicians may practice in individual or group settings

• Many group practices are made up of various medical specialties so that clients can have all their health care needs dealt with in one location


Clinics

• Outpatient clinics are associated with community hospitals, teaching hospitals, or public health departments

• Focus on people with chronic illnesses (diabetes or heart disease) but also treat people with acute illnesses

• Care in clinics: diagnose and treat current illness• Clinics offer physician and nursing services,

rehabilitation, prenatal care, well-baby checkups, immunizations, preventive dental and eye care, laboratory and diagnostic services


Figure 1-1


Health Maintenance Organizations

• Group practice with prepayment, voluntary enrollment, combination of hospital and outpatient facilities, emphasis on health promotion and illness prevention, and physician responsibility for direction of patient care

• Federal government enacted the Health Maintenance Organization Act • Helps private agencies develop methods of health

care delivery to control accessibility, quality, and cost


Ambulatory Care Centers

• Alternative to inpatient surgery • Located in hospitals, freestanding clinics,

health care centers, and physicians offices • Less costly and allows people to recover in

their own homes• After recovery from anesthesia, patient is

discharged, usually the same day


Home Health Agencies

• History of home health care• 1617: St. Vincent de Paul organized Daughters of

Charity • Members went from house to house, taking food,

education, and health care to the sick

• Mid-1800s: William Rathbone organized first district nursing organization; opened the first training school for visiting nurses in 1859

• 1893: Lillian Wald, forerunner of modern public health nursing, founded Henry Street Settlement


Focus of Home Health Care

• Services for clients in their homes or assisted living centers: promote, maintain, or restore health or minimize the effects of illness and disability

• Home health care one of fastest-growing fields • Medical and dental care, nursing care, physical

and occupational therapy, speech therapy, enterostomal therapy, social work, nutrition counseling, transportation, lab services, medical equipment and supplies, and the assistance of home health aides and homemakers


Funding of Home Care Services

• Paid for by individuals, private insurance, Medicare, and Medicaid

• Most nursing services paid for by Medicare must be skilled care; strict governmental guidelines define care that must be provided

• Medicare regulations for home care identify standard duties of the LPN, including furnishing health services, preparing progress notes, assisting the RN in special procedures, and assisting the patient in learning self-care techniques


Voluntary Agencies

• First to deliver nursing care in the home • Financed by wealthy philanthropists in the

community; mission was to care for the sick poor

• Visiting Nurses Association: most common example of a voluntary agency

• Usually governed by a community board of directors that determines service delivery policies and assists with fund-raising


Official Agencies

• Supported by tax dollars; authorized by law to deliver services to a defined area or community

• State, regional, and local health departments are responsible for health promotion and disease prevention services, communicable disease investigation, environmental health protection

• In most states, includes maternal and child services, sexually transmitted infection clinics, tuberculosis surveillance and treatment, and other health services as funds permit


Proprietary Agencies

• Organized to make a profit on their operation• May or may not participate in Medicare; most

do• May be owned by individuals or corporate

chains • Limitations imposed by the Balanced Budget

Act (1997) decreased profitability, and many have closed


Hospital-Based Agencies

• Usually governed by hospital’s board of directors

• Most referrals from the hospital itself• Philosophy and policies usually consistent with

those of parent institution


Outpatient Care


Home Health Care Services

• Physical therapy• For patients recovering from health problems

affecting mobility, such as hip fractures and strokes • Physical therapists assess need for walkers,

wheelchairs, and grab bars and work with patients on therapies to regain strength and mobility



• Speech therapy• Speech therapists work with patients who have

speech or swallowing disorders • A common indication for speech therapy is aphasia



• Occupational therapy• For conditions that impair upper-extremity

movement• People with arthritis or stroke may benefit from

assistive devices for dressing and other daily personal care and household activities

• Occupational therapists also provide muscle reeducation, splinting, and improved control of fine motor movement

• Timely occupational therapy can help the patient become safer and more independent in the home



• Social workers• Provide valuable assistance to families trying to

manage chronic illness in the home• Work with families to identify problems that arise in

managing illness at home and recommend referrals to community resources

• May provide information about financial assistance and help with applications for community services such as Meals-on-Wheels and respite care



• Home health aide services• Provide personal care, such as bathing, ambulating,

transferring, skin care, and oral hygiene, for the patient in the home

• Measure and record vital signs and do other basic, nonskilled tasks

• Homemaking tasks, such as making the bed and straightening the client’s room, are also common home health aide services



• Homemaker services• Usually provided by families or state and local

assistance programs • Duties include common household chores, such as

cooking, light housekeeping, laundry, shopping, and picking up medications



• Enterostomal therapy• Specialists in the care of all types of wounds, such

as pressure ulcers, surgical wounds, and ostomies• Provide care to patients and consultation to nurses

on how to manage wounds• Extensive knowledge of skin care products and

ostomy appliances



• Other home health care service providers• Dietitians• Nurse practitioners• Psychologists



• Specialty home care services• Pediatric: small, compact pumps, ventilators, and

monitors have enabled children with cancer, respiratory disease, and cerebral palsy to live more normal lives at home

• Mental health: provide medication monitoring and teaching and perform mental status examinations and suicide assessments


Hospice

• May be delivered in the home, acute care hospital, or extended care facility

• Provide care for terminally ill patients in the home and other specified facilities

• Purpose: enable terminally ill patients to live as full a life as possible, with skilled personnel managing pain, discomfort, and other symptoms associated with the illness


Adult Daycare Centers

• Services and activities• Promote health and socialization• Benefit the elderly and mentally ill• May be associated with hospitals or nursing homes,

or function independently • Allow older people to live supervised in the

community during the day while the family is at work

• Centers provide health-related services, health promotion programs, nutritional meals, and social activities

• Fees are based on a sliding scale fee or free


Inpatient Care


Hospitals

• Vary greatly in size, shape, and organization • Some hospitals are public and financed by the

local, state, or federal government; others are private and owned by churches, businesses, corporations, or charitable organizations

• Most frequent reasons for hospitalization are infant delivery, cardiovascular disease, chest pain, pneumonia, and depression

• Transitional and subacute facilities provide intermediate levels of care after hospital discharge


Figure 1-3


Psychiatric Hospitals

• Inpatient and outpatient treatment for acute psychiatric illnesses; focus on helping clients control their behavior or restore their behavior to what it was before entering the hospital• May be private, nonprofit organizations that are

sponsored by organized churches or run by local, state, or federal governments


Rehabilitation Centers

• Restore individuals to former level of functioning or maintain or maximize remaining function

• Located within the hospital or nursing home or in a freestanding residential institution

• May focus on physical problems, such as those caused by stroke, spinal cord injury, or amputation, or on mental health problems, such as drug dependency or mental illness


Figure 1-4


Long-Term Care Facilities

• Originally described institutions attached to hospitals for recovery from acute illness

• Now describe several different kinds of institutions—nursing homes, convalescent homes, and some residential institutions—whose primary purpose is caring for people with chronic illnesses and physical impairments

• Focus is on those who do not need hospitalization but cannot care for themselves


Figure 1-2



• Independent living retirement centers• Offer services that permit residents to access the

level of care needed at a given point in time

• Boarding and personal care homes• Provide a room and meals and, in some cases,

minimal assistance and supervision• Residents of these facilities usually come and go as

they please



• Assisted living facilities• Permit a high degree of independence but usually

have limited access to nursing care • Help with medications; some treatments may be

provided• Residents often have kitchens; some group meals

are typically provided



• Intermediate-care skilled nursing facility• Provides care from a licensed nursing staff,

including rehabilitation for people who can regain function

• Services: medical and nursing care; physical rehabilitation; long-term ventilator care; wound care; pharmaceutical, dietary, and social services; dental care; and activities

• Federal regulations require an RN to serve as director of nursing and an LPN to be on duty at least 8 hours a day


Skilled Nursing Facility

• Residents must be in need of care that consists of observation during an acute or unstable phase of an illness, administration of enteral (tube) feedings or IV fluids, bowel and bladder retraining (for a limited period), administration of intramuscular or intravenous medications, or changing of sterile dressings

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