Health Care Systems and Health Care Sub-culture

By Kathleen Giuntoli, RN, MSN

HEALTH CARE DELIVERY SYSTEM

“A NETWORK OF SERVICES” AVAILABLE TO INDIVIDUALS SEEKING

TREATMENT OR PROMOTING OR MAINTAINING HEALTH

HEALTH CARE SERVICES

HEALTH CARE SETTINGS

ORGANIZATION OF HEALTH CARE DELIVERY SYSTEM

PRIVATE SECTOR

•Provider’s office -FEE FOR SERVICE

•PPO

•MANAGED CARE

PUBLIC SECTOR

•Local

•State

•Federal

•International

VOLUNTARY AGENGIES

•Non-governmental

•Not for profit

•Foundations

Private Sector

• Independent Practice– Fee for service

– Free choice of

a provider

– Disease oriented with limited illness prevention (PEs, immunizations and screenings)

– Private care in hospital

• Preferred Provider Organization (PPO)– Developed in 1980s

– Network of doctors and hospitals agree to give the sponsoring organizations discounts for their services.

– PPOs do not exercise tight management over

medical care.

– Criticism of PPO is inability to control cost.

MANAGED CAREPrivate Sector continued…

Health Maintenance Organizations (HMO)– Delivers comprehensive care and treatment services for a

group of enrollees who pay pre-negotiated and fixed payments.

• Example: Group Health or Kaiser-Permanente

– Provides care to maintain health (Prevention programs “free and clear”)

– Health care is obtained by hospitals, doctors and other providers who are participating with HMO.

– HMO is responsible to set standards of care (i.e.: NCQA)– Goal is to : increase quality, increase access to health

care and decrease costs– HEALTH PROMOTION, ILLNESS PREVENTION

CONTROLS COST

PUBLIC SECTOR

• Official and voluntary public agencies operating at local, state, federal and international level.– Local health departments of a town, city

county district. There is a chief health officer• Responsibilities: vital statistics,communicable

disease control, environmental health and safety, personal health services like maternal child health (MCH) and public health education

Public sector continued..

• State level– State health officer in

charge of (DOH)

– Responsibilities in policy, planning, and coordination of programs and services for local units under the jurisdiction.

• Federal Level– US Department of Health

and Human Services (DHHS) established in 1979, & concerned with the health of the nation.

– Major functions: assisting states and local communities with the

development of health resources, education and regulation.

Federal level continued…

– Assisting with delivery of health services to Americans. Medicare and Medicaid.

• Medicare (1965). -Social insurance program for people over age 65.

• Medicaid- welfare program providing partial health care services for low income people. Supported by Federal and State governments. (Washington State: Health Options and Basic Health Plan)

• Supporting and conducting research in health sciences and protecting the people against impure and unsafe foods, drugs, cosmetics and potential hazards, and providing national leadership for communicable disease control.

Voluntary Sector

• Not for profit health movement which began in 1882, stems from the good will and humanitarian concerns that are part of the non-government, free-enterprise heritage of the people in the United States.

• Purpose:to provide public and professional educational programs to improve services and quality of facilities and personnel.

• Funding comes from citizens, business and industry– Examples: American Red

Cross(funded by Rockefeller and Ford Foundations) National Prevention of Blindness, National Association for Mental Health.

– Professional organizations: American Medical Association (AMA) or National League of Nursing (NLN)

What Effects Health Care Costs?

• Death rate• Lower birth rate• Greater longevity

– Elderly: by 2010, 40 million Americans or 14% of population will be >65 y/o, with 4.3 million over age 85. (People over age 85 are fastest growing group in US)

• Other effects on health care costs– Family diversity- the

shrinking family (only 26 % of American households with children under 18 y/o include married couples.

– Cultural diversity– Lifestyle (cause of death:

heart disease, stroke, cancer and COPD)

– Economic factors– Affluence/Poverty– Technology

HEALTH CARE SERVICES

Types of health care according to the needs

of the client.

• PRIMARY CARE

• SECONDARY CARE

• TERTIARY CARE

Primary Preventative Care

• Initial contact with family practice provider in an office or clinic.

• Primary care is directed toward health promotion and specific protections against illness (such as smoking cessation, car safety restraints, dietary controls, etc.)

• Teaching breast

self-exam• Immunizations• Accident prevention

education (child safety locks, etc.)

• Family planning

Secondary Preventative Care

• Focus on early detection of disease, prompt intervention and health maintenance for pts. experiencing health problems.

• Includes referrals to facilities for additional testing, consultation, and diagnosis.

Examples of activities :

•Providing wound care, giving medications, exercising arms and legs, assessing children for normal growth and development

•. Encouraging regular medical &

dental screenings.

-Primary care doctor refers you to cardiologist for cardiac catheterization after getting back your cholesterol tests, hearing of your chest pain and noting your SOB while ambulating up stairs.

Tertiary Preventative Care

• Begins after an illness is diagnosed and treated & is aimed at rehabilitating patient and restoring them to maximum level of functioning.

• Activities would include:– Caring for the cardiac

surgery pt. after surgery

– Teaching pt. w/diabetes how to recognize and prevent further complications

– Referring a women to a support group after breast removal (mastectomy)

– Teaching a brain stem injured pt. to walk.

HEALTH CARE SETTINGSWHERE DO WE GET OUR CARE?

INPATIENT SETTINGS:HOSPITALS-function is to deliver patient

services, diagnostic and therapeutic for particular general medical condition.

EMERGENCY DEPT/TRAUMA CENTER-functions : triage care of acutely ill and

injured clients, 24 hours/day as well as walk –in services for less acutely ill clients.

Where do we get care? In -patient Continued…

• Psychiatric facilities- function of inpatient facility is to provide diagnostic and treatment services for clients with psychiatric –related illnesses

• Rehabilitation centers- long term services offered to clients who need additional therapy or treatment for recovery from an injury or illness.

• Long term care (LTC) –range of services from skilled nursing, adult family homes and assisted living.

• Hospice- special services that addresses needs of the dying patient

Outpatient settings

• Physician offices• Ambulatory care

centers• Rural primary care

hospitals• Emergency and

rescue systems

• Adult day care• Respite care• Case management

programs• School health clinics• Industrial health services• Home health• Neighborhood

community centers• Free clinics

Community Settings

Health Care Trends

• Computer use –emailing your doctor

• Health care in shopping centers

• Decentralizing services: birthing centers, outpatient surgery centers, dialysis centers

• Emergency centers/ “doc in the box”,

walk in care

Health care team(1 out of 10 Americans work in health care)

• Primary care– Nurses, physicians,

physician assistants, ARNPs.

– Allied members-technologists, pharmacists, social workers, alternative practitioners, spiritual and religious personnel.

• Dietitians• Respiratory therapists,

PT, OT, etc.

Summary

• Health care systemNetwork of services

available to individuals

seeking treatment for a health

problem or assistance with

maintaining or promoting

health

• Health care services– Primary, Secondary or

Tertiary care

• Health care settings– Inpatient– Outpatient– Community Settings

• Health care trends- technology, “doc in the box,” services, decentralized services

• Health care team: diverse professional group that works together to assist individuals with attaining, maintaining and regaining health.