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Competency 6 & 7: Health Care Delivery Systems & Organizational Structure Dede Carr, BS, LDA Karen Neu, MSN, CNE, CNP Slide 2 U.S. Department of Labor Grant This workforce solution was funded by a grant awarded by the U.S. Department of Labors Employment and Training Administration. The solution was created by the grantee and does not necessarily reflect the official position of the U.S. Department of Labor. The Department of Labor makes no guarantees, warranties, or assurances of any kind, express or implied, with respect to such information, including any information on linked sites and including but not limited to, accuracy of the information or its completeness, timeliness, usefulness, adequacy, continued availability, or ownership. This solution is copyrighted by the institution that created it. Internal use, by and organization and/or personal use by an individual or non-commercial purposes, is permissible. All other uses require the prior authorization of the copyright owner. 2 Slide 3 Competency #6: Health Care Delivery Systems & Organizational Structure Competency: Describe selected types of healthcare facilities/systems including Organizational & financial structure Departments & services Types & levels of healthcare personnel Common policies and requirements. Slide 4 Competency #7: Health Care Delivery Systems & Organizational Structure Competency: Describe the different healthcare delivery systems Slide 5 What is a health care system? Levels of Health Care Services Slide 6 What is a health care system? Definition: The total services offered by all health disciplines and the method to pay for them (Berman, Snyder, Kozier, & Erb) Purpose of the health care system: Provide care for ill & injured Health promotion Illness & disease prevention Levels of wellness Services categorized by types & levels of care Slide 7 Healthcare Delivery System Elements 1. Organizational Structure 1. Public: Government (Federal, State, Local) 2. Private: For Profit/Non-Profit 2. Oversight & Management 3. Health Care Services 1. Direct & Indirect Care 2. Public & Private Providers 3. Health Promotion & Disease Prevention 4. Treatment of Disease 5. Rehabilitation/Special Needs 6. Hospice/Adult Day Care (Berman et al.) 1. Finance Mechanisms 1. Out of Pocket 2. Private Insurance 3. Managed Care Organizations 4. Public Insurance 5. Public Funding 2. Resources 1. Facilities 2. Personnel 3. Equipment 4. Supplies 3. Recipient of Care (Consumer: Patients/Families/Populations) Slide 8 Health Care Delivery System Overview Berman, A., Snyder, S.J., Kozier, B., & Erb, G. (2008). Health care delivery systems. In A. Berman, S.J. Snyder, B. Kozier, & G. Erb (Eds.). Kozier & Erbs Fundamentals of nursing: Concepts, process, and practice (8 th ed.) (pp. 101-116). Upper Saddle River, NJ: Prentice Hall Slide 9 Types of Healthcare Services Levels of Prevention Primary : Health promotion & disease prevention Immunizations/Vaccinations, Smoking Cessation Secondary : Diagnosis & Early Treatment Screenings such as mammograms, PAP tests, mantoux Lifestyle changes to prevent disease, Ex. low cholesterol diet, start a physical activity program, medications Tertiary : Rehabilitation, Health Restoration, & Palliative Care Rehabilitation after a stroke or injury Comfort care for the terminally ill (Berman et al) Slide 10 Primary Prevention Actions to protect against disease & disability Focuses on Health & Wellness Not on Illness Immunizations, Ensuring supply of safe drinking water Applying dental sealants to prevent tooth decay Actions to prevent accidents Government & state requirements for workplace safety Wearing seatbelts Not driving drunk Wearing proper protective equipment on the job (Net Industries and its Licensors) Slide 11 Primary Prevention Health Promotion includes the basic activities of a healthy lifestyle: Good nutrition & hygiene Adequate exercise Adequate rest Avoidance of environmental & health risks Limiting exposure to sunlight, using sunscreen, & wearing protective clothing (Net Industries and its Licensors) Slide 12 Primary Prevention Mental Health Teach children communication & interpersonal skills Conflict management Relationship & life skills that foster emotional resiliency Health Education Programs aimed at wellness: Stress management Parenting classes Preparation for retirement from the workforce Cooking classes (Net Industries and its Licensors) Slide 13 Secondary Prevention Goal of Secondary Prevention To identify & detect disease in its earliest stages, before noticeable symptoms develop, when it is most likely to be treated successfully. With early detection & diagnosis, it may be possible to cure a disease, slow its progression, prevent or minimize complications, & limit disability Prevent the spread of communicable diseases (illnesses that can be transmitted from one person to another) (Example: H1N1 Influenza, sexually transmitted diseases) Preventive services: screening to detect & identify wide range of conditions: high blood pressure, depression, obesity, & sexually transmitted diseases Screening in medical offices, clinics, schools, health fairs (Net Industries and its Licensors) Slide 14 Tertiary Prevention Aim to improve the quality of life for people with various diseases by Limiting complications & disabilities Reducing severity & progression of disease Providing rehabilitation (therapy to restore function & self-sufficiency) Involves actual treatment for the disease & conducted primarily by health care practitioners, rather than public health agencies Possible to slow the natural course of some progressive diseases and prevent or delay many of the complications associated with chronic diseases such as arthritis, asthma, diabetes, & heart disease For mental health, have outreach programs that monitor persons with mental disorders who live in the community to ensure that they adhere to their prescribed medication regimens (Net Industries and its Licensors) Slide 15 Acute & Sub-acute Care Hospitals Rehabilitation Centers Extended Care Facilities Medical, School, & Occupational Health Clinics Community/Public Health Care Agencies Home Health Care Agencies Hospice & Palliative Care Agencies Crisis Centers Adult Day Care Centers Slide 16 Types of Healthcare Delivery System Agencies/Services Hospitals Acute inpatient services Outpatient clinics/Ambulatory care services (ex. Same day surgery) Emergency services/Urgent Care Public Health Local, state, & federal levels (county & city level) Funding from taxes Preventative programs, direct patient care, protect the public from outbreaks of disease (Berman et al) Slide 17 Types of Healthcare Delivery Systems Agencies/Services Physicians Offices/Clinics May be primary care providers or general practitioners May be specialties: Dermatologist, Surgeons, Nurse Practitioners Occupational Health Clinics Worker safety & health; screenings Sub-Acute Care Facilities Variation of inpatient care (after acute hospitalization when still needing complex treatments) (Berman et al) Slide 18 Types of Healthcare Delivery System Agencies/Services Extended Care (Long-Term Care) Facilities Independent living quarters Assisted living facilities Skilled nursing facilities (Intermediate Care) Extended Care (Long-term Care) Retirement/Assisted Living Facilities Rehabilitation Centers Physical & mental care Drug & alcohol, gambling treatment/rehabilitation (Berman et al) Slide 19 Types of Healthcare Delivery System Agencies/Services Home Health Care Agencies (Public/Private) Offer education; comprehensive care to acute, chronic, & terminally ill patients, assistance with activities of daily living: bathing, preparing meals) Day-Care Centers: (many age groups) Ex. Elder Care: Socializing, exercise programs, stimulation, counseling, physical therapy Rural Care: Rural hospitals providing emergency care in rural areas/comprehensive primary care across the lifespan Hospice Services: Services for terminally ill, their families & support persons (Berman et al.) Slide 20 Types of Health Care Delivery Systems Agencies/Services Crisis Centers: Emergency services to clients experiencing life crisis to help them cope with immediate crisis, guidance & support for long-term therapy Mutual Support & Self-Help Groups: More than 500 mutual or self-help groups focusing on major health problems or life crisis School Health Centers Mental Health Clinics (Berman et al.) Slide 21 Government, Public, and Private Funding Sources Slide 22 Who pays for the healthcare services we need? For example, if you go to the doctor for a sore throat (strep infection) that requires antibiotic medication who pays for the services: Health care providers examination Laboratory test (throat culture) Antibiotic medication Not to mention others involved with a clinic visit, such as the billing department, receptionists, medical record technology? Slide 23 Payment for Healthcare Services See the following slides for various funding sources for health care Keep in mind that each type of funding source (insurance companies) covers specific services, some may require a co-pay which means that the person pays a small amount for each visit to the health care provider or for emergency care, etc. Some plans cover preventative care such as: biannual dental cleaning, annual physical examinations, What type of health care coverage do you have? Slide 24 Financing Health Care Governmental Funding Medicare Medicaid State Childrens Health Insurance Program (SCHIP) Supplemental Social Security Income Minnesota Care Veterans Health Tribal Indian Health Prospective Payment System Private Insurance Out-of-Pocket Group Insurance Health Maintenance Organizations (HMOs) Preferred Provider Organizations (PPO) Preferred Provider Arrangements (PPA) Independent Practice Associations (IPAs) Physician/Hospital Organizations (PHOs) Integrated Delivery Systems (IDS) (Berman et al.) Slide 25 Financing Healthcare Medicare coverage Persons 65 years & older, Workers with permanent disabilities & their dependents (receiving Social Security Disability Benefits) Medicare with supplemental insurance coverage (Drug Program; Supplement pays for costs not covered by Medicare) Medicaid (paid by federal & state government [taxes]) Supplemental Security Income (Persons with disabilities, blind, people not eligible for Social Security/Payments not restricted to healthcare costs) Can use for extended health care (Berman et al.) Slide 26 Financing Health Care State Childrens Health Insurance Program (SCHIP) Insurance coverage for poor & working-class children Expands coverage for children under Medicaid Subsidizes low-cost state insurance alternatives State eligible requirements vary: Children under 18 years of age & family earnings less than $34,100/year (Berman et al., pp.112-113) Slide 27 Financing Health Care Prospective Payment System Legislation limits amount paid to a hospital reimbursed by Medicare Reimbursements according to classification system diagnosis- related groups (DRGs) Hospital paid predetermined amount for clients with specific diagnosis Example: Hospital admits client with diagnosis of uncomplicated asthma is reimbursed a specific amount, regardless cost of services, length of stay, or acuity or complexity of clients illness Prospective payment or billing is formulated before client is even admitted to hospital (Berman et al.. p. 113) Slide 28 Financing Health Care Insurance Plans Private Insurance--Pays either entire bill or % of costs Not-for profit & For-profit Group Plans Health Maintenance Organization (HMO) Provides health maintenance & treatment services to voluntary enrollees Emphasizes wellness: Better health Fewer HMO services, greater profit for agency Choose own healthcare providers If client sees specialist, must have referral from primary care provider (Berman et al, p. 113) Slide 29 Financing Health Care Preferred Provider Organizations (PPO) Group of providers & health care agency (often hospitals) that provide an insurance company or employer health services at discounted rates Advantages Choice of health care providers & services Can belong to one or more PPO & choose providers from those PPOs Disadvantage May be slightly more expensive (Berman et al., pp. 113-114) Slide 30 Financing Health Care Preferred Provider Arrangements (PPA) Similar to PPO PPAs can be contracted with individual health care providers; Plan can be limited or unlimited Limited PPA restricts client to only preferred provider of health care Unlimited PPA permits use by any health care provider in the area who accepts contractual agreement of the plan More choices in health care providers may mean more cost to enrollee (Berman et al., p. 114) Slide 31 Financing Health Care Independent Practice Associations (IPAs) Similar to HMOs & PPOs Provides health care in offices/clinics as providers belonging to PPOs Difference from PPOs: Clients pay a fixed prospective payment to IPA & IPA pays the provider Some instances health provider bills IPA for services; Others, provider receives fixed fee for services given End of fiscal year any surplus money is divided among providers; any loss assumed by IPA (Berman et al, p. 114) Slide 32 Financing Health Care Physician/Hospital Organizations (PHOs) Joint ventures between group of private practice physicians & hospitals (Generally include primary care providers & specialists) Combine sources & personnel to provide managed care alternatives & medical services Work with variety of insurers to provide services Integrated Delivery Systems (IDS) Incorporates acute care services, home health care, extended & skilled care facilities, outpatient services; care throughout lifespan Insurers contract with IDS s to provide all required services rather than insurers contracting with multiple agencies for same services Enhances continuity of care & communication between professionals & various agencies providing managed care (Berman et al, pp. 114) Slide 33 Social Economic Political Technological Slide 34 Influences on Health Care System Berman, A., Snyder, S.J., Kozier, B., & Erb, G. (2008). Health care delivery systems. In A. Berman, S.J. Snyder, B. Kozier, & G. Erb (Eds.). Kozier & Erbs Fundamentals of nursing: Concepts, process, and practice (8 th ed.) (pp. 101-116). Upper Saddle River, NJ: Prentice Hall Slide 35 Factors Affecting Healthcare 1. Economics 2. Increase in number of elderly population 3. Advances in technology 4. Womens Health Movement 5. Uneven distribution of services 6. Demographic changes 7. Homeless & Poor 8. Access to health insurance 9. Affordable Health Care Act (Healthcare Reform Law) 10. Health Insurance Portability & Accountability Act (HIPPA) (Berman et al.) Slide 36 How Do Factors Affect Healthcare? Economics$$$$$$$$$$$$$ Existing facilities/equipment becoming obsolete Health care providers/patients want newest & best Total population growing with largest oldest, who tend to have greater health needs Recognition that health is everyones right, more are seeking assistance in health matters Increase in relative number of people providing health care services Increase in number of uninsured and underinsured Increase in cost of prescription drugs (Berman et al.) Slide 37 How Do Factors Affect Healthcare? Increase Number of Elderly Long-term illness, chronic diseases, require special housing, treatment services, financial support, social networks, special programs to remain in home Advances in Technology Improved diagnostic procedures & sophisticated equipment, new antibiotics & medications, surgical procedures, Laser, Computers (electronic medical records) Need highly specialized & trained personnel (Berman et al) Slide 38 How Do Factors Affect Healthcare? Womens Health Movement Research on womens health equalizing that of mens Change in health care practices: Provision of childbirth servicesbirthing centers Emphasis on psychosocial aspects of womens health: Impact of career, delayed childbearing, role of caregiver of older family member, extended life span (Berman et al.) Slide 39 How Do Factors Affect Healthcare? Uneven Distribution of Services Uneven distribution of healthcare providers Rural clients must drive further for care Fragmentation of care, & increased costs Increased specialization of healthcare providers Client may see 5-30 people during one hospitalization (Berman et al.) Slide 40 Factors Affecting Healthcare Delivery Access to Health Insurance Lack of insurance Income below or near poverty level Low income associated with higher rates of infectious diseases Loss of employment (Insurance through job) (Berman et al.) Slide 41 Factors Affecting Healthcare Delivery Affordable Healthcare Act (Healthcare Reform) Changes to health insurance coverage & who can have access to health insurance Emphasis of value of health changing to preventative strategies (Berman et al.) Slide 42 How Do Factors Affect Healthcare? Demographic Changes Increase numbers of single-parent families Families headed by women, so need childcare while working or assistance when child is ill Increase in cultural & ethnic diversityLanguage Communication; Slide 43 How Do Factors Affect Healthcare? Homeless & Poor Health problems related to conditions where homeless live, health problems often exacerbated, become chronic Lack convenient or timely transportation to healthcare facilities for homeless Improper nutrition, Lack of social support, Exposure to the elements, Questionable personal safety, Inadequate rest & privacy (Berman et al.) Slide 44 How Do Factors Affect Healthcare? Health Insurance Portability and Accountability Act (HIPAA) Protects privacy of individuals by safeguarding individually identifiable healthcare records In clinical healthcare sites/facilities/agencies/clinics Ancillary health care providers: Pharmacies, Laboratories, Third-party Payers (insurance companies, Medicare, Medicaid) (Berman et al.) Slide 45 Slide 46 Providers of Health Care Nurses Advanced Practice Nurses (Nurse Practitioners, Nurse Mid-wives, Nurse Anesthetist, Clinical Nurse Specialists, Certified Nurse Educator) Registered Nurses & Licensed Practical Nurses Unlicensed Assistive Personal (UAP) Nursing Assistants, Dental Assistants, Home Health Aides, Personal Care Attendants Case Manager: Ensure clients receive fiscally sound, appropriate care in the best setting Nurse, Social Worker, Physical Therapists, or other healthcare team members Slide 47 Providers of Health Care Alternative (Complementary) Care Provider Chiropractors, herbalists, acupuncturists, massage therapists, reflexologists, holistic health healers Physical, Occupational, & Respiratory Therapists Physician Physician Assistants-work under physician Hospitalist Psychiatrist Podiatrist Slide 48 Providers of Health Care Dentist Dental Hygienist Dental Assistant Dietitian Paramedical Technologist Pharmacist Social Worker Spiritual Support Personnel Chaplains, Pastors, Rabbis, Priests, & other religious advisors Slide 49 What is an organizational structure? Why is it important? Organizational Charts Slide 50 What is an organizational structure? Organizational structure refers to: The way in which a group is formed Its lines of communication Its means for channeling authority & making decisions Consists of activities such as task allocation, coordination & supervision, which are directed towards the achievement of organizational aims; It means who does what, who supervises whom, and who does one report to. (Organizational Structure of Nursing Service Department, n.d.) Slide 51 Types of Organizational Structures Formal Describes positions, tasks, responsibilities and relationships among people in their positions in the different departments in the organization, and presented in diagrammatic form called organizational chart. Informal Describes the personal and social relationships that do not appear on the organizational chart. (Organizational Structure of Nursing Service Department, n.d.) Slide 52 Informal Organizational Structure Helps members to meet their personal objectives & provides social satisfaction It has its own channels of communication, which may distribute information more broadly & rapidly than the formal communication system (conversation among employees) Informal type is important to management Supervisor is aware of its existence, studies its operating techniques & uses it to meet the organizational objectives. (Organizational Structure of Nursing Service Department, n.d.) Slide 53 Organizational Chart (Formal) Diagram shows the different positions & departments, & relationships among them Chart used to show The formal organizational relationships Areas of responsibility Persons to whom one is accountable Channels of communication (Organizational Structure of Nursing Service Department, n.d.) Slide 54 Sample of Organizational Chart Slide 55 Effective Organizational Chart 1. Its accurate, clear, simple & updated 2. Shows the chain of command, lines of authority, responsibility & relationships. 3. All members of department should be notified when any change occurs. (Organizational Structure of Nursing Service Department, n.d.) Slide 56 Advantages of Organizational Chart Quick visual illustration of organizational structure Shows lines of formal authority, responsibility & accountability Clarifies who supervises whom & to whom one is responsible Describes channels of communication Emphasizes the important aspect of each position Facilitates management development & training Used to evaluate strengths & weakness of current structure Helps in organizational planning & provides starting points for planning organizational changes (Organizational Structure of Nursing Service Department, n.d.) Slide 57 Disadvantages of Organizational Charts Does not show informal relationships Does not show duties or responsibilities (Organizational Structure of Nursing Service Department, n.d.) See following slides showing various organizational charts. Most agencies, facilities, departments, & industry have organizational charts. Some charts show a general view of departments & to whom those departments are responsible & report to. Charts usually are set from the top executives and include all employee positions. Slide 58 State Health Department Organizational Chart Example Berman, A., Snyder, S.J., Kozier, B., & Erb, G. (2008). Health care delivery systems. In A. Berman, S.J. Snyder, B. Kozier, & G. Erb (Eds.). Kozier & Erbs Fundamentals of nursing: Concepts, process, and practice (8 th ed.) (pp. 101-116). Upper Saddle River, NJ: Prentice Hall Slide 59 State Health Agency Chart Berman, A., Snyder, S.J., Kozier, B., & Erb, G. (2008). Health care delivery systems. In A. Berman, S.J. Snyder, B. Kozier, & G. Erb (Eds.). Kozier & Erbs Fundamentals of nursing: Concepts, process, and practice (8 th ed.) (pp. 101-116). Upper Saddle River, NJ: Prentice Hall Slide 60 US Dept. Health & Human Services Berman, A., Snyder, S.J., Kozier, B., & Erb, G. (2008). Health care delivery systems. In A. Berman, S.J. Snyder, B. Kozier, & G. Erb (Eds.). Kozier & Erbs Fundamentals of nursing: Concepts, process, and practice (8 th ed.) (pp. 101-116). Upper Saddle River, NJ: Prentice Hall Slide 61 Long-Term Organizational Chart Slide 62 Health & Home Care Agency Chart Slide 63 What is the Chain of Command? Chain of Command = Line of Authority and responsibility along which orders are passed within the department, the organization, and between units (Clavreul) Every healthcare delivery system has one indeed, nearly every organization, has a chain of command. In most cases, this chain of command is delineated with a chart, often referred to as an organizational chart. A person who uses the chain of command correctly protects the himself/herself, the patient, & ultimately the organization (hospital/clinic/agency) (Clavreul) Slide 64 Four Steps to Using Chain of Command First, call on the charge person (who can use position to accelerate a response or get the necessary authorization). [Some organizations chain of command may vary Important to know your organizations chain of command] Second, should this fail or if for some reason there is no charge person available, look to the Unit/Department head (may be Director of Nursing in hospital). Typically directors or department leaders hold a 9 to 5 position, yet they can be asked to intervene at any time should the need arise. (In other words, you may telephone him/her) (Clavreul) Slide 65 Four Steps to Using Chain of Command Third, always move up the Chain of Command if you get no response/action from the person you reported to. Example: if the person that you reported to does not respond/act, then contact the person immediately above & gradually move up the organizational chart until you get a response/action to the situation. Fourth, document. Always use facts about the event & not opinions or personal judgments of the situation. Example: If you are having trouble getting the appropriate authorization to administer medication or perform a procedure, be sure to note this in the chart. If necessary & appropriate, you can also complete an incident report as defined by your hospitals policies & procedures. Always rely on the hospitals policy & procedures regarding appropriate reporting protocols. (Clavreul) Slide 66 Chain of Command It is important to utilize the proper chain of command in dealing with any type of situation. Breaking the chain of command creates communication, follow-up & other management problems. Therefore, personnel should utilize the chain of command in all applicable situations. It is best to use common sense & a little cooperation to easily settle which situations dictate chain of command communication, & what is necessary to accomplish the task at hand. (Clavreul) Slide 67 Chain of Command Process Official communications both up & down the chain of command must not skip any rank. Any assignment given to any person should pass through all the appropriate ranks. Any request, comment, suggestion, complaint, etc. forwarded up the chain of command must start with the persons immediate supervisor. Example: Communication from a nursing assistant should not be first to the hospital administrator, but following the appropriate ranks up the organizational chart/structure(one by one) (Clavreul) Slide 68 References Berman, A., Snyder, S.J., Kozier, B., & Erb, G. (2008). Health care delivery systems. In A. Berman, S.J. Snyder, B. Kozier, & G. Erb (Eds.). Kozier & Erbs Fundamentals of nursing: Concepts, process, and practice (8 th ed.) (pp. 101-116). Upper Saddle River, NJ: Prentice Hall Clavreul, G.M. (2011). The nursing chain of command. WorkingNurse.com. Retrieved from http://www.workingnurse.com/articles/The-Nursing-Chain-of- Command The organizational structure of nursing service department. (n.d.). Retrieved from http://faculty.ksu.edu.sa/Hanan_Alkorashy/Nursing%20manage ment%20489NUR/8._The_organizational_structure_of_nursing _service_department.pdf