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Chapter 4

Chapter 4. Health Care Delivery, Quality, and the Continuum of Care. Health Care Delivery: Organizational Frameworks. Public sector Official or governmental agencies U.S. Department of Health and Human Services Voluntary agencies

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Chapter 4

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  1. Chapter 4 Health Care Delivery, Quality, and the Continuum of Care

  2. Health Care Delivery: Organizational Frameworks • Public sector • Official or governmental agencies • U.S. Department of Health and Human Services • Voluntary agencies • ANA, American Medical Association (AMA), American Cancer Society (ACS), and American Heart Association (AHA) • Nonprofit agencies (continued)

  3. Health Care Delivery: Organizational Frameworks • Private sector • All nongovernmental sources • Health insurance industry • Pharmaceutical companies • Suppliers of health care technology and equipment

  4. Health Care Team • Nurse (RN) • Physician (MD, DO) • Physician assistant (PA) • Pharmacist (RPh) • Dentist (DDS, DMD) • Dietitian (RD) (continued)

  5. Health Care Team • Social worker (SW) • Respiratory therapist (RT) • Physical therapist (PT) • Occupational therapist (OT) • Chaplain • Unlicensed assistive personnel (UAP)

  6. Nurse: Roles and Functions • Caregiver • Teacher • Advocate • Manager • Expert • Case manager • Team member

  7. Advanced Practice Nurse: Roles and Functions • Diagnose primary health problems • Prescribe therapies • Promote continuity of care • Specialize in variety of areas

  8. Reimbursement Methods • Private insurance • Managed care • HMO • Preferred provider organization (PPO) (continued)

  9. Reimbursement Methods • Government plans • Medicare • Medicaid • State Children’s Health Insurance Program (SCHIP)

  10. Factors Influencing the Delivery of Health Care • Cost • Access • Quality • Nursing supply and demand

  11. Cost • Contributing factors to high costs: • Aging population • Technological advances • Surplus of hospital beds • More people living with chronic illnesses • Barrier to access

  12. Access • Limiting factors: • No insurance • Cultural barriers • Few providers in rural and inner-city areas • Limited access to ancillary services

  13. Quality • Threats: • Inappropriate use of resources • Inappropriate substitution of personnel for registered nurses • Imbalance in supply and demand of registered nurses

  14. Nursing Supply and Demand • Nursing shortage could reach 500,000 by 2025 • Declining number of nursing faculty

  15. Responses to Health Care Changes • Nursing’s agenda for health care reform • Public versus private programs • Vulnerable populations • Community nursing organizations

  16. Continuum of Care • Levels of care • Health care settings • Fragmentation of care

  17. Levels of Care • Primary • Health promotion and illness prevention • Secondary • Diagnosis and treatment • Tertiary • Rehabilitation

  18. Health Care Settings • Hospitals • Extended care facilities • Home health agencies • Hospices • Outpatient settings (continued)

  19. Health Care Settings • Schools • Industrial clinics • Managed care organizations • Community nursing centers • Rural primary care hospitals

  20. Fragmentation of Care • Result of multiple providers and various care settings • Loss of individuality for client • Seamless service • Attempt to overcome delivery of fragmented services

  21. Quality Management in Health Care • Quality • Meeting or exceeding client requirements • Right thing • Right way • First time (continued)

  22. Quality Management in Health Care • Quality assurance • Continuous quality improvement • Total quality management

  23. Factors Influencing Quality • Consumer demands • Financial viability • Professional accountability • Regulatory requirements • Progress in quality improvement techniques • Changes in health care delivery (continued)

  24. Factors Influencing Quality • Legal implications of quality improvement • Nurses must understand roles that law, regulations, and ethics play in quality movement • Federal regulations • Agencies regulate health care standards • Imperative to adhere to standards

  25. Quality and Health Care Economics • Rising costs • Poor quality care • Doing more with less • Increasing efficiency and improving quality

  26. Principles of Quality Improvement • Quality as central theme • Organizational culture supports quality • Personal responsibility • Continual education • Monitored performance • Use of scientific approach • Accurate information

  27. Customer Satisfaction • Customers • Clients • Suppliers • Third-party payers • Families • Visitors • Employees • Community (continued)

  28. Customer Satisfaction • Satisfaction requires putting customer first

  29. Organizational Structure for Quality Management • Organizational culture • Leadership • Teamwork

  30. Process Improvement • Tools for measuring quality: • Audits • Peer reviews • Benchmarking • Clinical pathways

  31. Nursing’s Role in Quality Management • Roles: • Clinician • Team member • Manager • Must continue to strive for excellence

  32. Trends in Health Care Delivery • Aging U.S. population • Diversity • Single-parent families • Growth in outpatient settings • Technology • Disease prevention • More responsibility for care

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