kozier-chapter 6 -health care delivery system

Kozier & Erb's Fundamentals of Nursing, 8eBerman, Snyder, Kozier, ErbCopyright 2008 by Pearson Education, Inc.

Chapter 6

Health Care Delivery Systems

Copyright 2008 by Pearson Education, Inc.

Question 1

Which of the following is an example of a primary prevention activity?

1. Antibiotic treatment of a suspected urinary tract infection.

2. Occupational therapy to assist a client in adapting his or her home environment following a stroke.

3. Nutrition counseling for young adults with a strong family.

4. History of high cholesterol.5. Removal of tonsils for a client with recurrent

tonsillitis.


Rationales 1

1. Antibiotic therapy is secondary prevention.

2. Rehabilitation efforts following an illness are considered tertiary prevention.

3. Correct. Actions such as diet modification that help to prevent an illness or detect it in its early stages are primary prevention.

4. Surgery is secondary prevention.


Question 2

Which of the following statements is true regarding types of health care agencies?

1. Hospitals provide only acute, inpatient services.2. Public health agencies are funded by

governments to investigate and provide health programs.

3. Surgery can only be performed inside a hospital setting.

4. Skilled nursing, extended care, and long-term care facilities provide care for the elderly whose insurance no longer covers hospital stays.


Rationales 2

1. Hospitals may provide a variety of wellness and clinic programs in addition to inpatient services.

2. Correct. City, county, state, or federal government funds pay for health department and agency activities aimed at the global health of the community.

3. Surgery may be performed in outpatient surgery centers and physicians’ offices in addition to within hospitals.

4. Skilled nursing, extended care, and long-term care facilities provide care to persons of all ages who require rehabilitation or subacute care. This is not necessarily related to insurance coverage for hospital stays.


Question 3

In most cases, clients must have a primary care provider in order to receive health insurance benefits. If a client is in need of a primary care provider, it is most appropriate for the nurse to recommend which of the following?

1. Family practice physician2. Physical therapist3. Case manager/discharge planner4. Pharmacist


Rationales 3

1. Correct. Primary care providers are limited to generalist physicians and advanced practice nurses. In some cases a gynecologist may qualify as a primary care provider and in other cases not.

2. Physical therapists do not have a scope of practice broad enough to serve as primary care providers.

3. Pharmacists are not responsible for providing direct client care.

4. Case managers/discharge planners are not responsible for providing direct client care.


Question 4

The most significant method for reducing the ongoing increase in the cost of health care in the United States includes controlling which of the following?

1. Number of children according to the family's income.

2. Numbers of uninsured and underinsured persons.

3. Number of physicians and nurses nationwide.4. Competition among drug and medical

equipment manufacturers.


Rationales 41. The number of children is increasing, but in the United

States and Canada this is a nonmodifiable factor. Also, the majority of health care costs are incurred by adults and elders who tend to have multiple and chronic health conditions.

2. Correct. When people have inadequate insurance for health costs, they tend to avoid early and preventive care. This results in eventual use of much more costly resources such as emergency rooms. Methods to provide minimum levels of insurance coverage have been successful in other countries.

3. There is currently a significant shortage of nurses and maldistribution of physicians so reducing their numbers would only worsen the problem.

4. Competition among manufacturers is more likely to cause costs to fall than to rise.


Question 5

A client is seeking to control health care costs for both preventive and illness care. Although no system guarantees exact out-of-pocket expenditures, the most prepaid and predictable client contribution would be seen with:

1. Medicare.2. An individual fee-for-service insurance.3. A preferred provider organization (PPO).4. A health maintenance organization (HMO).


Rationales 5

1. Medicare covers a minimal number of preventive and outpatient services so the cost cannot be anticipated.

2. Individual fee-for-service insurance is perhaps the most costly to the client, with potentially large differences between the amount of coverage the insurance company pays and the provider’s charges.

3. Correct. A health maintenance organization involves a set monthly membership fee and predictable visit or deductible costs.

4. PPOs are less costly than fee-for-service but more expensive than HMOs.


Types of Health Care Services

• Primary prevention– Health promotion– Illness prevention

• Secondary prevention– Diagnosis– Early detection– Treatment


Types of Health Care Services

• Tertiary prevention– Rehabilitation– Health restoration– Palliative care


Health Care Agencies

• Government agencies– Public health services

• Physicians’ offices– Primary care– Routine health screening– Diagnosis and treatment



• Government agencies– Public health services

• Physicians’ offices– Primary care– Routine health screening– Diagnosis and treatment



• Ambulatory care centers– Diagnostic treatment facilities– Minor surgery

• Occupational health clinics– Run by companies for employees– Health promotion activities



• Hospitals– Acute inpatient services– Outpatient and ambulatory care– Emergency department– Hospice care

• Subacute care– Variation of inpatient care– Technically complex treatments



• Extended care facilities (formerly called nursing homes)– Independent living– Assisted, skilled, extended care facilities– Rehabilitation– Custodial care

• Retirement and assisted-living centers– For clients unable to stay at home, but

do not require hospital or nursing home



• Rehabilitation centers– Restore or recuperate health– Drug and alcohol

• Home health care agencies– Education to clients and families– Care to acute, chronic, or terminally ill

• Rural care hospitals– Federal funding– Services for rural residents



• Day-care centers– Infants or children– Adults that cannot be left at home

• Hospice services– Care for dying in home or facility– Improve or maintain quality of life until

death



• Crisis centers– Emergency services for life crises– Counseling and support

• Mutual support or self-help groups– Health problems– Life crises


Health Care Professionals

• Nurses• Alternative (complementary) care

providers• Case manager• Dentists• Dietitians• Nutritionists



PT designsstrengtheningand balanceexercise plan

MD developsmedical care plan,

prescribesmedications and

treatments

Resp Therapistprovidesbreathing

treatments Pharmacistsupplies and

teaches aboutmedications

Casemanager

communicatescare plan to

family and otherproviders

OT designsself-care activities

that reserveclient's energy

Dieticiancreates

low-salt diet

RNdevelopsnursing

care plan

73-year oldwith heart

failure, short ofbreath



• Alternative (complementary care providers)

• Dentists• Nurses• Nutritionists• Occupational

therapists • Paramedics/EMTs• Pharmacists

• Physical therapists • Physicians• Physician assistants• Podiatrists• Respiratory therapists• Social workers• Spiritual support

personnel• Unlicensed assistive

personnel (UAPs)


Factors that Affect Health Care Delivery

• Increasing number of elderly• Advances in technology • Economics• Women’s health issues• Uneven distribution of services • Access to health insurance• Homeless and the poor• HIPAA• Demographic changes


Number of Nurses per 100,000 Population Map


• For adults over 65• Part A provides hospitalization, home

care, hospice• Part B provides partial outpatient and

physician services (voluntary)• Part D prescription plan (voluntary)• Does not cover dental, eyeglasses,

hearing aids, etc.

Medicare


Medicaid

• Financial assistance• Each state is distinct


Supplemental Security Income

• Benefits for people with disabilities• For those not eligible for Social

Security


State Children’s Health Insurance Program (SCHIP)

• Insurance coverage for poor and working class children

• Includes primary care, prescriptions, hospitalization


Prospective Payment System

• Limits amount paid to hospitals that are reimbursed by Medicare


Private Insurance Plans

• Not-for-profit and For-profit• Most often pay 80% of costs


Health Care Group Plans

• Provide blanket medical service in exchange for monthly payment– Health Maintenance Organization (HMO)– Preferred Provider Organization (PPO)– Preferred Provider Arrangements (PPA)– Independent Practice Associations (IPA)– Physician/Hospital Organizations (PHO)


Post Test

• Use your clickers to complete the following post test.


Question 1

Which of the following is an example of a primary prevention activity?

1. Antibiotic treatment of a suspected urinary tract infection.

2. Occupational therapy to assist a client in adapting his or her home environment following a stroke.

3. Nutrition counseling for young adults with a strong family.

4. History of high cholesterol.5. Removal of tonsils for a client with recurrent

tonsillitis.