Online Companion: Fundamentals of Nursing Standards and Practice 2E

Chapter Summary

Chapter 4 introduces the reader to the health care delivery system in which nurses practice. It focuses on the U.S. health care delivery system, its overall organization and economic structure. Health care services are categorized into three levels: primary, secondary and tertiary. The primary level focuses on health promotion and illness prevention. This is a relatively new type of service focus, occurs in community settings and emphasizes the development of healthy lifestyles. Services within the secondary type of health care are diagnosis and treatment. The predominant site of delivery of these services is the acute care hospital. In tertiary type settings, the purpose is rehabilitative care in which the client is helped to reach an optional level of self-care following illness. Health care services in the U.S. are offered by the public and private sectors. The U.S. Department of Health and Human Services is administratively responsible for health care services delivered to the public.

Health care services are delivered by a multidisciplinary team. Nurses are important members of this team. The roles and functions of other professionals on the team are described in Chapter 4.

The funding of health care comes from both private and public sources. In Canada, the government is the only source of health care costs reimbursement. The financing of health care in the U.S. is based on the private insurance model in which insured individuals pay monthly premiums for access to health care.

Managed care is a system of providing and monitoring care in which access, cost and quality are controlled before or during delivery of services. It is designed to provide cost-effective and coordinated services with emphasis on prevention and primary care. One variation of a managed care structure is the health maintenance organization (HMO). This is a prepaid health plan that provides primary health care services for a preset fee with a focus on cost-effective treatment. One common feature of HMOs is the use of primary care providers as "gatekeepers" to the health care system in that they determine which, if any, referrals to specialists are needed by the client. The most common managed care system is the preferred provider organization (PPO) which is a contractual relationship between hospitals, providers, employees and third-party payers to form a network of health services for a defined population at a predetermined price.

Despite cost containment efforts such as DRGs and managed care, the U.S. health care system continues to have problems providing adequate access to services especially for low-income and unemployed individuals. Health care costs continue to rise; attempts to control costs run the risk of compromising the safety and quality of care.

The major challenges facing the U.S. health care delivery system are identified as the public's disillusionment with providers, loss of control over health care decisions, decreased use of hospitals and the impact on quality of care, changing practice settings, ethical issues and vulnerable populations. The nursing profession has responded to these challenges by proposing a plan for reform of the health care system. The proposed agenda and its basic premises advocate for a health care system that is accessible and user-friendly to the client. Empowerment of consumers for self-care is another major feature of the plan. Other approaches supported by nursing include standardization of care, use of nurses in advanced practice roles, integration of public and private sector resources, a community-based approach to service delivery and increased financial support for long-term care needs of older adults.