Coordinating Health Care F09


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  • Today we are going to talk about coordinating healthcare. Let’s begin this discussion with some definitions of health and some models that look at health in different ways.
  • The most widely accepted definition of health is that of the World Health Organization (WHO). It states that "health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" (WHO, 1946). In more recent years, this statement has been modified to include the ability to lead a "socially and economically productive life." The WHO definition is not without criticism, as some argue that health cannot be defined as a state at all, but must be seen as a process of continuous adjustment to the changing demands of living and of the changing meanings we give to life. The WHO definition is therefore considered by many as an idealistic goal rather than a realistic proposition. Defined on individual terms-A state of being that people define in relation to their own values, personality, and lifestyle Each individual defines a state of health differently. A client can have a disability or disease, but still feel healthy. Now, let’s look at four different models of health and illness that help define health and wellness better for us.
  • This model is not discussed in your book, but is a common model used to define health and illness. The illness/wellness continuum pictured here was first developed by Dr. John Travis in 1972.  As you are reading, think of the continuum as a pathway.  You can walk in either direction on the path.  A person who is in good health, but always complaining or worrying might be standing to the RIGHT of the neutral point, BUT definitely facing towards the LEFT – towards pre-mature death.  Similarly, another person who’s in a state of discomfort, or is handicapped physically or mentally, can still have a genuinely positive/optimistic outlook and therefore facing to the RIGHT in the direction of high level wellness.   
  • The term wellness was coined in the 1950s by Dr. Halbert Dunn. But what exactly does this word mean? In his book High Level Wellness, Dunn calls wellness "an integrated method of functioning which is oriented toward maximizing the potential of which the individual is capable of functioning within the environment.“ A philosophy expounded upon by Dr. Dunn, introduced the concept of "wellness" as a "process involving a zest for living." The "total person" as described by Dr. Dunn, has a social, spiritual, intellectual, emotional, and, last but not least, physical dimension. Let’s look at what each circle of wellness means- Social -The social component of wellness means having the ability to interact successfully with people and one's personal environment. Environment - The environmental component of wellness includes the ability to promote health measures that improve the standard of living and quality of life in the community, including laws and agencies the safeguard the physical environment. Occupational - The occupational dimension of wellness comprises aspects of wellness that help achieve a balance between work and leisure in a way that promotes health and a sense of personal satisfaction. Intellectua l- Intellectual Wellness involves the ability to learn and use information effectively for personal, family, and career development. Spiritual - The spiritual component of wellness provides meaning and direction in life and enables you to grow, learn, and meet in new challenges. Physical - The physical component of wellness involves the ability to carry out daily tasks, develop cardio respiratory and muscular fitness, maintain adequate nutrition and a healthy body fat level, and avoid abusing alcohol and other drugs or using tobacco products. Emotional - Emotional Wellness is the ability to control stress and to express emotions appropriately and comfortably.
  • The Health Belief Model (HBM) is a psychological model that attempts to explain and predict health behaviors. This is done by focusing on the attitudes and beliefs of individuals . The HBM was first developed in the 1970s by social psychologists Rosenstoch, Becker and Maiman working in the U.S. Public Health Services. This model addresses the relationship between a person’s beliefs and behaviors. It provides a way of predicting how clients will behave in relation to their health and how they will comply with health care therapies. The model was developed in response to the failure of a free tuberculosis (TB) health screening program. Since then, the HBM has been adapted to explore a variety of long- and short-term health behaviors, including sexual risk behaviors and the transmission of HIV/AIDS. The first component of this model involves the individual’s perception of susceptibility to an illness. Example- a client with familial link for Breast cancer. The second component is the individual’s perception of the seriousness of the illness. This perception is influenced and modified by demographic and psychosocial variables The third component is the likelihood that a person will take preventive action that results from the person’s perception of the benefits of and barriers to taking action. When we look at our example of a woman with a history of breast cancer in their family, we know they have a risk, but how serious to they take this risk. Do they perform self breast exams every month, or do they think it won’t happen to them, and self exams are too much of a hassle. If they were to get info from their physician and start seeing TV adds about breast cancer would they be more likely to perform self exams? Do they believe finding a lump early improve chance for recovery from breast cancer? All of these factors play into whether or not they will take action to perform self breast exams.
  • This model was developed by a nurse educator- Nola J. Pender, PhD, RN, FAAN (1982, and revised in 1996).It defines health as a positive, dynamic state, not merely the absence of disease. Health promotion is directed at increasing a clients level of well-being. The health promotion model describes the multidimensional nature of persons as they interact within their environment to pursue health. The model focuses on the following three areas Individual characteristics and experiences Behavior-specific knowledge and affect Behavioral outcomes Each person has a unique personal experience that effects the persons health promoting behaviors and therefore nursing decisions and actions. Nola Pender believed that these variables within people can be modified through nursing actions that will lead to health promoting behaviors and the desired behavioral outcome.
  • We discussed this theory earlier today in our basic psychosocial needs lecture.
  • Is health care in the U.S. a right, or just access to health care? These are the questions being asked in today’s political arena. Access to services can be very difficult for those with limited or no health care insurance. Managed care has changed how those with insurance access their system. They have to figure out who provides care and how that care is furnished. If they don’t go through the proper channels they might very well receive sub-standard care. Clients must now know what questions to ask and what they can do to receive all the care their organization can offer. Continuity of care is another major problem. If insurance changes and a client moves from one physician or service to another, often times little information is passed on about the client’s needs or planned treatment. Acute care has changed because many who would have been hospitalized for their condition 10 years ago are now treated in outpatient facilities or in the home. Clients who are hospitalized truly do require acute care, they are sicker and their treatment involves a higher level of technological management. Clients are discharged from hospitals sooner, often leaving families with the burden of providing care in the home.
  • The health care system of the new millennium has become less service oriented and significantly more business oriented in light of cost-saving initiatives. To become leaders in health care, nurses must understand the health care system and the issues that affect how care is provided. During most of the 20 th century there were few incentives for controlling health care costs. The doctor was the one who chose what to order for a client’s care and treatment (this is often referred to as “physician prescription” and does not mean just medicine ordered, but other tests and treatments). In other words, the doctors ran the show and ordered whatever they wanted. However, this resulted in out of control health care costs with total health expenditures growing from $41.9 billion in 1965 to $425 billion in 1985. Out of this financial crisis, Utilization Review was created. UR committees and/or UR nurses review admissions, Dx testing, treatments, length of stay. They make recommendations to doctors, insurance companies, etc. to help control costs. Prospective payment system- the PPS eliminated cost-based reimbursement. Hospitals serving Medicare clients were no longer paid for all costs incurred to deliver care to a client. Instead, inpatient hospital services for Medicare clients were bundled into 468 DRG’s. Each group has a fixed reimbursement amount with adjustments for the severity of a case. This system has provided a strong incentive for hospitals to better monitor the care of clients and reduce length of stay of all clients. Capitation- is the payment mechanism in which providers receive a fixed amount per client or enrollee of a health care plan. This method puts pressure on the hospitals to manage clients effectively, yet with the best standards of care. For select diagnoses or surgical procedures- essential diagnostic and treatment procedures are included. Managed Care describes health care systems in which there is administrative control over primary health care services (HMO’s and organizations like Kaiser). The HMO contract determines what treatments and procedures are reimbursed.
  • The health care industry is moving toward health care practices that emphasize managing health rather than managing illness. The premise is that in long term health promotion reduces health care costs. A wellness perspective focuses on the health of populations and the communities in which they live rather than just on finding a cure for an individual’s disease. This would push more health care dollars into preventative and primary care, rather than waiting for the client to become ill and need secondary (hospital setting) or higher care The health care system provides six levels of care (see figure) Levels of care describe the scope of services and setting where health care is offered to clients in all stages of health and illness.
  • School health services- approximately 50,000 licensed professional school nurses provide health services to children and youth in the school setting. Effective school health services are comprehensive programs that integrate health promotion principles throughout a school’s curriculum. Specific nursing interventions in the school setting include health education, parent programs and counseling, communicable disease control, physical assessment, crisis intervention, environmental safety, nutrition planning and emergency care. Occupational health services are health services provided in the work setting that focus on health promotion and accident or illness prevention. Recurring issues that nurses face in the work site are drug testing, right-to-know issues, concerns r/t AIDS, and exposure to environmental hazards. Physician’s offices- Physicians in office practices tend to focus on the diagnosis and treatment of specific illnesses rather than on health promotion. Managed care is changing this practice thought and requiring physicians to look beyond diagnosis and to screen for possible health problems. A lot of physicians have started hiring APN’s that have a more holistic approach and can address education, counseling and community referrals. Clinics- sometimes call Ambulatory health services, offer a variety of diagnostic and treatment services. Often, a clinic is focused on a specific client population, such as well-baby, mental health and allergy. Nursing centers- Typically, nursing centers serve vulnerable populations such as minority and ethnic groups of low-income status, older adults, and the disabled. NP’s and CNS’s typically manage a nursing center, however, PHN’s may also be actively involved. Block and parish nursing are two nontraditional settings where preventive and primary care can be found. Block nursing happens where nurses live. They offer their services to friends, church groups, girl scouts, etc. Parish nursing is the same as block nursing, except in churches and synagogues.
  • Within preventive care and primary care are concepts like the 3 levels of prevention. Nurses oriented to health promotion, wellness and illness prevention can be understood in terms of primary, secondary and tertiary prevention.
  • Primary- Primary prevention is true prevention. It precedes disease or dysfunction and is applied to clients considered physically and emotionally healthy. Includes health education, immunization, physical and nutritional fitness activities. Role of the nurse- education, screening for risk factors, counseling, anything that has to do with health promotion. example- offering a class on benefits of physical fitness, dietary education Secondary-Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are risk for developing complications. It focuses on early detection and prompt intervention so that complications can be avoided. Role of the nurse-screening techniques and treating early stages of disease to limit disability by averting or delaying the consequences of advanced disease. Example- teaching a client who has diabetes how to monitor his blood sugar and how to control his carbohydrate intake. Tertiary- Tertiary prevention occurs when a disease or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability by interventions directed at preventing deterioration . Care at this level aims to help clients achieve as high a level of functioning as possible, despite the limitations caused by illness or impairment. Role of the nurse- helping client achieve as high a level of functioning as possible. Many of these nurses work in Rehabilitation centers, clinics (cancer), home health. example- a patient with an amputee learns how to walk with a prosthesis and how to care for the stump. A patient with cancer is able to live as near normal life as possible with treatment and interventions.
  • ANS: C c. The goal of tertiary prevention is to preclude further deterioration of physical and mental function in a person who has an existing illness, and to have the client use whatever residual function is available for maximal enjoyment of and participation in life’s activities. By eating a well-balanced diet he can prevent further exacerbations and hospitalizations. a. Primary prevention is aimed at general health promotion. b. Secondary prevention is aimed at early recognition and early treatment of disease to prevent complications. This person has already suffered complications and has been hospitalized often for their disease. d. Health promotion is aimed at reducing the incidence of disease and its impact on people. REF: Text Reference: p. 53
  • Hospital emergency depts. and urgent care centers, critical care units, and inpatient med/surg units are the sites where secondary and tertiary levels of care are provided. Tertiary care refers to hospitals that supply a higher level of service than other facilities and often do specialty procedures. Loma Linda is a tertiary center in our area that does specialty surgeries, such as heart transplants, etc. Psychiatric facilities- clients who suffer emotional and behavioral problems, such as depression, violent behavior and eating disorders often require special counseling and treatment in psychiatric facilities. Located in hospitals, independent outpatient clinics, or private mental health hospitals.
  • We’ll be talking more about home health in a minute. Rehabilitation centers and Extended care facilities often provide intermediary care between the acute care setting and the home. Patients who have recently been admitted to the acute care hospital but who cannot take care of themselves may be placed for a short time in a transitional care setting.
  • Home health nursing falls under restorative care because a good percentage of home care services occur following hospitalizations. Nursing is the most common service that is offered under Medicare, but other services can be ordered, such as P.T., O.T., Speech therapy, R.T. Nurses who work in the home care setting can work in a variety of specialties. Home care is unique, with nurse providing care in the client’s environment. Home health nurses do a variety of care, from assessment (functional ability of an older adult) to actual interventions (IV therapy). They see a variety of patients, from the newborn to the elderly. For this reason, family dynamics, cultural practices, spiritual values and communication principles are very important knowledge areas for the home health nurse. The home health nurse is a “jack of all trades” and every visit, every patient, presents new problems and needs.
  • Hospice is a specialized type of home care (and also sometimes in the hospital) that provides support and care for persons in the last phases of incurable diseases. Many people choose to die at home in the comfort of their own home and surrounded by family and friends. Without heroic measures, commonly seen in acute care setting, a patient can die in dignity.
  • Continuing care describes a collection of health, personal, and social services provided over a prolonged period to persons who are disabled, who never were functionally independent, or who suffer a terminal disease. Most who fall into this needs category are the elderly, who have no immediate family members to care for them. However, it can also include those who are mentally or physically handicapped and need constant care or assistance. Agencies on Aging- The Older Americans Act (OAA) of 1965 established a national network of federal, state and area agencies on aging, which are responsible for providing a range of community services for older adults. This can include multipurpose senior citizen centers, church community centers, and town halls that serve as focal points. The types of services offered include information and referral for medical and legal advice, psychological counseling, pre and post retirement planning, programs to prevent abuse, neglect and exploitation of seniors, programs to enrich life through educational and social activities. Nursing facilities or Nursing Centers is the official term for skilled nursing facilities where long-term care is provided. A nursing center typically provides 24 hour intermediate and custodial care where nursing, rehabilitation, social and religious services for residents who live there. In long-term care, the philosophy is to provide a planned, systematic and interdisciplinary approach that helps residents reach and maintain their highest level of function. The nursing center industry has become one of the most highly regulated industries in the U.S. to prevent inadequate care or abuse. Assisted living is one of the fastest growing industries in the U.S. There are approximately 32,000 assisted living facilities. Assisted living offers an attractive long-term care setting with a homier environment and greater resident autonomy. Clients are generally in need of some assistance with the ADL’s, but remain relatively independent. Usually each resident has their own room or apartment, but shares dining and social activity areas. The greatest limitation to assisted living is that most residents pay privately. There are no government fee caps and little regulation. Adult day care centers offer care during the day only, so that family members can maintain their lifestyles and employment and still provide home care for their relatives. These centers are generally open M-F, and closed on weekends.
  • Community based health care and nursing involves the acute and chronic care of individuals and families that enhances their capacity for self-care and promotes autonomy in decision making. Care takes place in community settings such home or a clinic, or workplace, and church. The community health nurse comes to understand the needs of a population or community through experience with individual families and working through their social and health care issues. The successful community health nurse needs to build relationships within the community and help change to occur through education and advocating for changes in resources. An example would be a community nurse who has a high % of homeless people in their area of service. This nurse would work at setting up shelters, free health care days, involving churches to reach out to this population, etc.
  • Factors influencing change: In many instances the implementation of DRG’s has shifted patient care from acute care to community settings. Hospitals are no longer reimbursed for all costs, so it is in their best interest to discharge patients more quickly and have them followed up at home by home health nurses. Patients are sent home earlier than they used to be, and have greater needs for education and home care. This is the biggest reason that there is an increase in community health care. Changing demographics- caring for more aging Americans has put a strain on the medicare programs. Expanded life expectancy has contributed to an increase of chronic conditions. Health care is shifting from intervention toward early screening, detection, and prevention. New technologies have improved surgical and diagnostic procedures. Surgical centers care for many outpatient surgeries that used to be done in the hospital setting. The public seeks out information about their health from the media and internet. Patients are becoming more involved in their health care and demand a certain level of care. *Ask students to describe what personal changes they have experienced in their own health care delivery. Have them describe the services offered by their own insurance plans or HMOs.
  • ANS: C c. Because hospital stays are being shortened to control health care costs, clients are returning home more acutely ill. This is the largest contributing factor to the increase in the need for and use of home care. a. Government funding of home care is not the largest contributing factor to the increase in the need for and use of home care. b. The existence of more single-income families is not the largest contributing factor to the increase in the need for and use of home care. d. Seven-days-per-week services are available for the elderly in a variety of settings, such as in acute care or long-term care, not just in the home care setting. Being able to provide daily services for the elderly in the home care setting is not the largest contributing factor to the increase in the need for and use of home care. REF: Text Reference: p. 47
  • Evidenced-based practice: nurses are challenged to stay familiar with new information in order to provide the highest quality of client care. Nursing practice is dynamic and always changing because of new information coming from research studies, practice trends, and technological developments. Electronic Health records- Nationwide implementation of EHRs would allow patients to transfer their information between health care facilities more easily. For example, physicians treating a patient in the emergency room could call up that person's medical information from another doctor. It would also help public health officials identify disease outbreaks or potential bioterrorism attacks more quickly. HIMSS is the biggest organization that focuses on providing global leadership for the optimal use of healthcare information technology (IT) and management systems for the betterment of healthcare. Americans are utilizing more alternative methods of healing, chiropractic, accupuncture, herbs, neutraceuticals (these will continue as standard healthcare costs continue to rise. Internet medical sites and MD advice web sites are becoming more popular. What about a nursing web site? One has started in the UK. Will the U.S. follow suit?
  • What are some ways nurses can be involved in the future of health care? Have students answer
  • Coordinating Health Care F09

    1. 1. Coordinating Health Care Delivery Sandie Freeman, RNC, MSN
    2. 2. Definition of Health <ul><li>WHO – “ State of complete physical, mental and social well being – not merely the absence of disease or infirmity.” </li></ul><ul><li>Good health is often synonymous with “Wellness” </li></ul><ul><li>Health or wellness are defined on individual terms </li></ul>
    3. 3. <ul><li>Health / Illness Continuum Model </li></ul>Dr. John Travis, 1972
    4. 4. High level wellness model Dr. Halbert Dunn, 1950’s
    5. 5. Health Belief Model Rosenstock, Becker and Maiman, 1974
    6. 6. Health Promotion Model Nola Pender, PhD, RN, 1996
    7. 7. Basic Human Needs Model Dr. Abraham Maslow, 1970
    8. 8. Health Care Delivery System <ul><li>Access to services </li></ul><ul><li>Continuity of health care </li></ul><ul><li>Changes in acute care facilities </li></ul><ul><li>The Dilemma- How can health care in the U.S. be financed so that services are produced efficiently, costs are effectively controlled, and quality is maintained or improved? </li></ul>
    9. 9. Health Care Regulation <ul><li>Utilization Review (UR) </li></ul><ul><li>Prospective payment system </li></ul><ul><li>-DRG’s (diagnosis-related groups) </li></ul><ul><li>Capitation </li></ul><ul><li>Managed Care </li></ul>How is health care paid for?
    10. 10. Emphasis on Population Wellness <ul><li>Health care industry emphasis is shifting from managing illness to managing health. </li></ul><ul><ul><li>Dietary habits </li></ul></ul><ul><ul><li>Immunizations </li></ul></ul><ul><ul><li>↓ in tobacco use </li></ul></ul><ul><ul><li>Injury prevention programs (seat belts, child safety seats, helmet laws) </li></ul></ul><ul><ul><li>Screening (mammograms, fecal occult blood test, eye exams, pap smears) </li></ul></ul>
    11. 11. Levels of Health Care -Preventative -Primary -Secondary -Tertiary -Restorative -Continuing
    12. 12. Preventive and Primary Care Settings <ul><li>School health services </li></ul><ul><li>Occupational health services </li></ul><ul><li>Physicians’ offices </li></ul><ul><li>Clinics </li></ul><ul><li>Nursing centers </li></ul><ul><li>Block and parish nursing </li></ul>
    13. 13. 3 Levels of Prevention
    14. 14. LEVELS OF PREVENTION CHART Tertiary Secondary Primary Examples Role of the Nurse Focus Level of Prevention
    15. 15. <ul><li>A client has a history of a gastrointestinal (GI) disease with eight hospitalizations over the past 21-year period. He tries to eat a well-balanced diet that usually keeps his GI symptoms suppressed. Which level of prevention corresponds to his dietary management? </li></ul><ul><li>a. Primary prevention </li></ul><ul><li>b. Secondary prevention </li></ul><ul><li>c. Tertiary prevention </li></ul><ul><li>d. Health promotion </li></ul>Think!
    16. 16. Secondary and Tertiary Care Settings <ul><li>Hospitals/medical centers </li></ul><ul><ul><li>Emergency departments </li></ul></ul><ul><ul><li>Medical units </li></ul></ul><ul><ul><li>Intensive care </li></ul></ul><ul><li>Psychiatric facilities </li></ul>
    17. 17. Restorative Care Settings <ul><li>Home health care </li></ul><ul><li>Rehabilitation centers </li></ul><ul><li>Extended care facilities </li></ul>
    18. 18. Home Health Nursing
    19. 19. Hospice <ul><li>Hospice is not a place, but a concept of care that provides compassion, concern and support for the dying. </li></ul><ul><li>Dignity </li></ul><ul><li>No heroic measures </li></ul><ul><li>Comfort of friends, family and their own home </li></ul>
    20. 20. Continuing Care Settings <ul><li>Agencies on aging </li></ul><ul><li>Nursing Facilities/Centers </li></ul><ul><li>Assisted living </li></ul><ul><li>Adult day care centers </li></ul>
    21. 21. Community Health Nursing <ul><li>Merges Public Health Sciences with professional nursing theories to safeguard and improve the health of populations in the community </li></ul><ul><li>Includes care in: </li></ul><ul><li>the Home </li></ul><ul><li>clinics </li></ul><ul><li>workplace </li></ul><ul><li>church </li></ul>
    22. 22. Shift from hospital to community <ul><li>Patient care is shifting from acute care to community-based and home care settings. </li></ul><ul><li>Factors influencing change </li></ul><ul><li>-more cost effective </li></ul><ul><li>-changing demographics </li></ul><ul><li>-nature and prevalence of illness </li></ul><ul><li>-technology </li></ul><ul><li>-increasing consumerism </li></ul>
    23. 23. Think one more time! <ul><li>The nurse recognizes that a greater need exists for comprehensive community health care. Which of the following is the largest contributing factor for the increase in the need for and use of home care? </li></ul><ul><li>a. Government funding of the home care setting has increased greatly. </li></ul><ul><li>b. The existence of more single-income families has increased the need for their elderly relatives to receive care in the home. </li></ul><ul><li>c. Clients are more acutely ill when discharged from the acute care facility. </li></ul><ul><li>d. Seven-days-per-week services are available for the elderly in home care agencies. </li></ul>
    24. 24. The future of Health Care <ul><li>Evidenced-Based Practice </li></ul><ul><li>Electronic Health Records (EHR) </li></ul><ul><li>HIMSS (Healthcare Information and Management Systems Society) </li></ul><ul><li>Increased use of “Alternative” therapies </li></ul><ul><li>“ e” health care (Cyber-Docs, Web MD) </li></ul><ul><li>eMedicine World Medical Library: Allergy-Immunology </li></ul><ul><li>Welcome to the e-health nurses network </li></ul>
    25. 25. What will Nursing’s contribution be to the future of healthcare? <ul><li>Nurses number 2.7 million and rank as the nation’s largest healthcare profession. </li></ul><ul><li> </li></ul>