Read chapter 10, 11 & 12 of the class textbook and review the attached PowerPoint presentations. Once done answer the following questions;
Chapter 11
The Health Care System
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
U.S. Health Care System
Figure 11-1
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
2
U.S. Health Care System (Cont.)
Private health care subsystem
➢
➢
➢
➢
Focus on the individual
Nonprofit and for-profit agencies
Models of services
• Solo practice
• Single specialty group practice
• Multispecialty group practice
• Integrated health maintenance model
• Community health center
Voluntary or nonofficial agencies
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
3
U.S. Health Care System (Cont.)
Public health care system
➢
Mandated by the U.S. Constitution
➢ Focus on the population
• “promote the general welfare of its citizens.”
➢ Federal policies and practices influence local and
state governments
➢ Coordination of services under Department of
Health and Human Services
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4
Public Health
Public health refers to the efforts organized by society
to protect, promote, and restore the people’s health.
➢ Concerned with a healthy population
➢ Concerned with a healthy environment
➢ Scope is broad
➢ Encompasses activities that promote good health
➢ Organized into multiple levels (federal, state, local)
➢ Provides services for those unable to obtain health
care without assistance
➢ Establishes laws, rules, and regulations to protect the
public
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
5
Public Health System
Federal level subsystem
➢
➢
➢
➢
U.S. Department of Health and Human
Services
Surgeon General and numerous other
agencies
Targets general population, special
populations, and international health
IOM Report, HHS in the 21st Century:
Charting a New Course for a Healthier
America (2008), recommended
transformation of system
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6
Current HHS Strategic Plan
1. Transform health care
2. Advance scientific knowledge and innovation
3. Advance health, safety, and well-being of the
American people
4. Increase efficiency, transparency, and
accountability of HHS
5. Strengthen the nation’s health and human
services infrastructure and workforce
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7
Public Health System (Cont.)
State level subsystem
➢
State health departments
➢ Responsible for the health of their citizens
➢ Central authorities in the public health care system
➢ Dependent on federal level for guidance and
resources
➢ Establish own state laws
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8
Public Health System (Cont.)
Local health department subsystem
➢
Local health departments (LHD)
➢ Responsible for direct delivery of public health
services and protection of the health of citizens
➢ Not all communities have LHDs
➢ Responsible for:
• Community health services
• Environmental health services
• Personal health services
• Mental health services
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9
Health Care Providers
Provider organizations
➢
Health care professionals
➢
Any organization that provides health care to the
community
The interprofessional health care team
• Professionals and nonprofessionals
Nontraditional health care providers
➢
Complementary and alternative therapies
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10
Quality Care
To Err Is Human: Building a Safer Health System
(IOM, 1999) focused on safety within the health care
delivery system
Crossing the Quality Chasm (IOM, 2001) focused on
developing a new health care system for the twentyfirst century, one that improves care
Leadership by Example (IOM, 2003) was a report
requested by Congress that examined the federal
government’s quality enhancement processes
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11
Quality Care (Cont.)
Who Will Keep the Public Healthy? (IOM,
2003) brought public health into the forefront
by focusing on issues including globalization,
rapid travel, scientific and technological
advances, and demographic changes
➢
➢
In-depth exploration of educational needs for
improved public health
Need for appropriately prepared public health
professionals
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12
Quality Care (Cont.)
Who Will Keep the Public Healthy? (Cont.)
➢
New content areas for public health professionals:
• Informatics, genomics, communication, cultural
competence, community-based anticipatory research,
global health, policy and law, and public health ethics
➢
Old content areas for public health professionals:
• Epidemiology, biostatistics, environmental health, health
services administration, and social and behavioral
science
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13
Quality Care (Cont.)
Health Professions Education (IOM, 2003),
the education of all health professionals is
viewed as a bridge to quality care.
➢
Provide patient-centered care
➢ Work in interdisciplinary teams
➢ Employ evidence-based practice
➢ Apply quality improvement
➢ Utilize informatics
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14
Quality Care (Cont.)
Priority Areas for National Action (IOM, 2003)
identified priority areas that should be addressed to
improve quality
➢
➢
➢
➢
➢
➢
➢
➢
Patient and family engagement
Population health
Safety
Care coordination
Palliative care
Overuse
Access
Health systems infrastructure capabilities
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15
Quality Care (Cont.)
• Keeping Patients Safe: Transforming the
Work Environment (IOM, 2004) addressed
critical quality and safety issues with a focus
on nursing care and nurses
• Focused on nurses in acute care and the work
•
environment for safer patient care
Also looked at nursing shortage, health care
errors, patient safety risk factors, nurse’s role in
quality improvement, and work environment
threats to patient safety
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16
Quality Care (Cont.)
The Future of Nursing. Leading Change,
Advancing Health (IOM, 2011) focuses on the
nursing profession and how it might fit into
the change process
1. Nurses should practice to the full extent of their
education and training.
2. Nurses should achieve higher levels of education
and training through an improved education
system that promotes seamless academic
progression.
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17
Quality Care (Cont.)
The Future of Nursing. Leading Change,
Advancing Health (Cont.)
3. Nurses should be full partners with physicians
and other health professionals in redesigning
health care in the United States.
4. Effective workforce planning and policy making
require better data collection and an improved
information infrastructure.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
18
Accreditation
Joint Commission
National Committee for Quality Assurance
(NCQA)
➢
Health Plan Effectiveness Data and Information
Set (HEDIS)
American Healthcare Commission
Consumer Assessment of Healthcare
Providers and Systems (CAHPS)
Agency for Healthcare Research and Quality
(AHRQ)
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19
… the ultimate test of the public health
subsystem is whether it effectively serves the
people by their measurements, not those of the
public health profession.
– Koop (1989)
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20
Critical Issues in Health Care
Delivery
Managed care
Information technology
➢
➢
➢
Consumer advocacy and client rights
➢
Telehealth
Electronic medical records (EMRs)
Social media
Client/consumer-centered health care
Coordination and access to care
Disparity in health care delivery
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21
Critical Issues in Health Care
Delivery (Cont.)
Globalization and international health
➢
World has no real boundaries
➢ CDC active in responding to preparedness and
international travel
➢ WHO fosters collaborative global initiatives
➢ ICN gives nursing perspective
Health care reform
➢
➢
The Clinton Health Reform Initiative
Patient Protection and Affordable Care Act of 2010
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22
Future of Public Health
●
●
●
●
●
What services?
Who has access?
Who pays?
How is it delivered?
What is the role
of government?
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23
Impact on Community Health
Nursing
Principles of change that focus on quality,
access, and cost…
➢
The need for patient-centered care
➢ The need for stronger primary care services
➢ The need to deliver more care in the community
➢ The need for seamless, coordinated care
➢ The need for reconceptualized roles for health
professionals
➢ The need for interprofessional collaboration
– The Future of Nursing. Leading Change,
Advancing Health (IOM, 2011)
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24
Chapter 12
Economics of Health Care
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Factors Influencing Health Care
Costs
Historical payment systems
Unnecessary use of services
Lack of preventive care
Lifestyle/health behaviors
Societal belief that disease would be eradicated
Technological advances
Aging of society
Utilization of drugs
Shift from nonprofit to for-profit health care
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2
Public Financing of Health Care:
Medicare
Entitlement program to provide health care to
the growing population of those 65 years of
age or older
Part A
➢
➢
➢
Includes inpatient care in
hospitals/skilled nursing facilities,
hospice care, some home health care
Must pay a deductible for health
services
Does not pay for all health care costs of
enrollees; co-payments required after
60 days
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3
Public Financing of Health Care:
Medicare (Cont.)
Entitlement program to provide health care to the
growing population of those 65 years of age or older
Part B
➢
Purchased by monthly fee
➢ Not compulsory
➢ Helps pay for out-of-pocket costs for physician
services, hospital outpatient care, durable medical
equipment, and other services, including some
home health care
➢ Enrollees must pay deductibles and coinsurance
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
4
Public Financing of Health Care:
Medicare (Cont.)
Entitlement program to provide health care to the
growing population of those 65 years of age or older
Part C
➢
Medicare Advantage Plans
➢ Optional “gap” coverage
➢ Provided by private insurance companies
approved by, and under contract with, Medicare
➢ May include HMOs and PPOs
➢ May include vision, hearing, dental care, and other
services not covered by Medicare Parts A, B, or D
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5
Public Financing of Health Care:
Medicare (Cont.)
Entitlement program to provide health care to the
growing population of those 65 years of age or older
Part D
➢
Initiated in 2006 to help defray costs of
prescription drugs
➢ Optional; must enroll in an approved prescription
drug plan
➢ Monthly premium, deductibles, and co-payments
➢ Must pay 100% of costs when costs reach
“coverage gap” or “donut hole”
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6
Public Financing of Health Care:
Medicaid
Title XIX of the Social Security Act—a public welfare
assistance program
Provides universal health care coverage for the
indigent and children
A joint state and federal venture
Eligibility for this program depends on the size and
income of the family; federal government sets
baseline eligibility requirements, but states can lower
eligibility
Priority participation is given to children, pregnant
women, and the disabled
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7
Public Financing of Health Care:
Medicaid (Cont.)
Federal government sets baseline services,
but state governments may provide more
services
➢
Must include inpatient and outpatient hospital
care, pregnancy-related care, vaccines for
children, family planning services, rural health
clinics, home health care, lab and x-ray services,
and EPSDT
Care by pediatric and family nurse
practitioners is covered
Children under 18 also eligible for Children’s
Health Insurance Program (CHIP)
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
8
Public Financing of Health Care:
Governmental Grants
Directed toward funding large populations
and different aggregates
Historically for health promotion and
disease prevention measures
Administered by DHHS
“Block grants” provided to states to impact
the health of the public as a whole
Health care providers and programs
compete for funds through grant proposals
and applications
Closely related to Healthy People 2020
objectives
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9
Philanthropic Financing of
Health Care
Often research or disease oriented
Eligibility for services limited to the specific
disease or population of interest
➢
➢
➢
May include services rendered plus ancillary needs
like transportation, parental housing, or wigs
Informational and research activities constitute the
majority of services provided by these organizations
Examples include American Heart Association and
the Shriners
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10
Health Insurance Plans
First established in 1930s
Types of plans
➢
➢
Reimbursement mechanisms
➢
Indemnity, HMO, PPO, POS
Private insurance, cooperatives, cafeteria plans
Retrospective and prospective plans
Scope of services covered
➢
Routine care, catastrophic, ambulatory
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11
Cost Containment
Capitated reimbursement
➢
Access limitation
➢
➢
Prospective reimbursement for services
Primary care provider as gatekeeper
Managed care plans—preauthorization
requirements for additional services
Rationing
➢
Determining the most appropriate use of health
care or directing the health care where it can do
the most good
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
12
Trends in Health Financing
New and innovative health
care approaches
Cost sharing
Health alliances
Self-insurance
Flexible spending
accounts
Health promotion and
disease prevention
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13
Health Care Financing Reform
Lack of insurance is the major factor associated
with lack of access to medical care.
The current dilemma is how to provide health
care to all Americans that is acceptable and
affordable.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
14
Caring for the Uninsured
Should health care be one of those
necessities available to all without
cost?
Should health care be a right for all
rather than a commodity to be
available only to those who can afford
it?
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
15
Access to Health Care—Barriers
Insufficient financial support
Physical barriers
➢
Structural inaccessibility, lack of appropriate
equipment, or inability to communicate
➢ Inequality in the distribution of services,
transportation difficulty, conflict with work hours,
and failure to provide services
Sociological barriers
➢
Language difficulties and fear of reprisals
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16
Health Care Reform 2010
Individual mandate
Employer requirements
Expansion of Medicaid
Expansion of CHIP
Premium and cost-sharing subsidies to
individuals
Changes to private insurance
Cost-containment provisions
Prevention and wellness
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17
Nurse’s Role in Economics
Researcher
➢
➢
Investigate efficient, cost-effective care, culturally
sensitive treatment modalities, health education,
disease prevention, and factors to change
behaviors
Investigate, develop, and evaluate the
effectiveness of health promotion and disease
prevention
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
18
Nurse’s Role in Economics
(Cont.)
Educator
➢
➢
➢
➢
Health education is the foundation of community
health nursing practice
Understand that knowledge empowers clients to
actively participate in their health care
Demonstrate the effectiveness and value of
education
Outcome measures for health education need to
be established
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19
Nurse’s Role in Economics
(Cont.)
Provider of care
➢
Care must be appropriate, necessary, and cost
effective.
➢ Judicious application of the nursing process is
imperative.
➢ Serve as program service provider, health
education provider, and heath program participant
➢ Participate in grant proposal process, program
design, and evaluation of these programs
➢ Participate in statistical information–gathering
process as basis for determining needs
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20
Nurse’s Role in Economics
(Cont.)
Advocate
➢
Become more involved in the economics of health
care
➢ Increase knowledge of health care funding and
policy making
➢ Use political power to influence health care
funding
➢ Advocate for increase in health promotion/disease
prevention funding
➢ Plan programs, seek funding, and evaluate
program effectiveness through outcome measures
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21
Chapter 1
Health: A Community View
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Community/Public Health Nursing …
… is the synthesis of nursing practice and
public health practice.
… has the major goal to preserve the health
of the community and surrounding
populations.
… focuses on health promotion and health
maintenance.
… is associated with health and identification
of populations at risk rather than an episodic
response to patient demand.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
2
The mission of public health is …
… social justice, which entitles all people to
basic necessities such as adequate income
and health protection and accepts collective
burdens to make this possible.
http://www.health.gov/phfunctions/public.htm
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
3
How Do We Define Health?
A state of complete well-being, physical, social, and
mental, and not merely the absence of disease or
infirmity.
– World Health Organization, 1958
The extent to which an individual or group is able, on
the one hand, to realize aspirations and satisfy
needs; and, on the other hand, to change or cope
with the environment. Health is, therefore, seen as a
resource for everyday life, not the objective of living;
it is a positive concept emphasizing social and
personal resources, and physical capacities.
– World Health Organization, 1986
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4
Community …
… a group or collection of locality-based
individuals, interacting in social units and
sharing common interests, characteristics,
values, and/or goals.
Nies and McEwen, 2013
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5
Figure 1-2
From U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion. Federal
Interagency Workgroup: The vision, mission, and goals of Healthy People 2020.
http://www.healthypeople.gov/2020/Consortium/HP2020Framework.pdf. Accessed July 2013.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
6
Healthy People 2020 Leading
Health Indicators
Access to Health
Services
Clinical Preventive
Services
Environmental
Quality
Injury and Violence
Maternal, Infant, and
Child Health
Mental Health
Nutrition, Physical
Activity, and Obesity
Oral Health
Reproductive and
Sexual Health
Social Determinants
Substance Abuse
Tobacco Use
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7
Public and Community Health
Public health is the Science and Art of …
(1) preventing disease,
(2) prolonging life, and
(3) promoting health and efficiency through organized
community effort…
C.E. Winslow…
Community health extends the realm of public
health …
…to include organized health efforts at the
community level through both government and
private efforts.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
8
Core Public Health Functions
Assessment: Regular collection, analysis, and
information sharing about health conditions, risks,
and resources in a community.
Policy development: Use of information gathered
during assessment to develop local and state health
policies and to direct resources toward those policies.
Assurance: Focuses on the availability of necessary
heath services throughout the community. It includes
maintaining the ability of both public health agencies
and private providers to manage day-to-day
operations and the capacity to respond to critical
situations and emergencies.
– Institute of Medicine (1988)
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9
10 Essential Services
Assessment
➢
➢
➢
Monitor health status to identify community health
problems.
Diagnose and investigate health problems and
health hazards in the community.
Research for new insights and innovative
solutions to health problems.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
10
10 Essential Services (Cont.)
Policy Development
➢
➢
➢
➢
Inform, educate, and empower people about
health issues.
Mobilize community partnerships to identify and
solve health problems.
Develop policies and plans that support individual
and community health efforts.
Research for new insights and innovative
solutions to health problems.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
11
10 Essential Services (Cont.)
Assurance
➢
➢
➢
➢
➢
Enforce laws and regulations that protect health
and ensure safety.
Link people to needed personal health services
and ensure the provision of health care when
otherwise unavailable.
Ensure a competent public health and personal
health care workforce.
Evaluate effectiveness, accessibility, and quality of
personal and population-based health services.
Research for new insights and innovative
solutions to health problems.
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12
The Three Levels of Prevention
Primary prevention
➢
➢
Secondary prevention
➢
➢
Prevention of problems before they occur
Health promotion and health protection
Early detection and intervention
Early diagnosis and treatment
Tertiary prevention
➢
➢
Correction and prevention of deterioration of a
disease state
Limitation of disability and rehabilitation
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13
The Three Levels of Prevention
(Cont.)
Figure 1-2
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14
Level of Prevention—Individual
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15
Level of Prevention—Family
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16
Level of Prevention—Group
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17
Level of Prevention—Community
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18
Healthy People 2020
Vision
➢
A society in which all people live long, healthy lives.
Overarching Goals
➢
➢
➢
➢
Attain high-quality, longer lives free of preventable disease,
disability, injury, and premature death.
Achieve health equity, eliminate disparities, and improve the
health of all groups.
Create social and physical environments that promote good
health for all.
Promote quality of life, healthy development, and healthy
behaviors across all life stages.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
19
Healthy People 2020
(Cont.)
HP2020 has 42 focus areas
➢
The objectives and related information and
materials can help guide health promotion
activities and can be used to aid in communitywide initiatives.
(USDHHS, 2013)
➢
All health care practitioners…
• should focus on the relevant areas in their practice
• incorporate objectives into programs, events, and
publications whenever possible
• use them as a framework to promote healthy cities and
communities
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
20
Healthy People 2020 Topic
Areas
1.
2.
3.
4.
5.
6.
7.
8.
Access to Quality Health
Services
Adolescent Health New
Arthritis, Osteoporosis and
Chronic Back Conditions
Blood Disorders and Blood
Safety New
Cancer
Chronic Kidney Disease
Dementias, including
Alzheimer’s Disease New
Diabetes
9.
10.
11.
12.
13.
14.
15.
16.
Disability and Secondary
Conditions
Early and Middle Childhood
Educational and
Community-based
Programs
Environmental Health
Family Planning
Food Safety
Genomics New
Global Health New
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21
Healthy People 2020 Topic
Areas (Cont.)
17. Health Communication and
18.
19.
20.
21.
Health Information
Technology
Healthcare-Associated
Infections New
Health-Related Quality of
Life and Well-Being New
Hearing and Other Sensory
or Communication Disorders
Heart Disease and Stroke
22. HIV
23. Immunization and Infectious
24.
25.
26.
27.
28.
Diseases
Injury and Violence
Prevention
Lesbian, Gay, Bisexual, and
Transgender
Health New
Maternal, Infant, and Child
Health
Medical Product Safety
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22
Healthy People 2020 Topic
Areas (Cont.)
29. Mental Health and Mental
30.
31.
32.
33.
34.
35.
36.
37.
Disorders
Nutrition and Weight Status
Occupational Safety and
Health
Older Health New
Oral Health
Physical Activity
Preparedness New
Public Health Infrastructure
Respiratory Disease
38. Sexually Transmitted
39.
40.
41.
42.
43.
Diseases
Sleep Health New
Social Determinants of
Health New
Substance Abuse
Tobacco Use
Vision
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23
Public Health Nursing
ANA definition (2007)
➢
➢
➢
The practice of promoting and protecting the
health of populations
Uses knowledge from nursing, as well as social
and public health sciences, to promote and protect
the health of populations.
Is population focused, with the goals of promoting
health and preventing disease and disability for all
people
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
24
Community Health Nursing
ANA definition (1980)
➢
Synthesis of nursing practice and public health to
promote and preserve the health of populations
➢ Care is directed to individuals, families, groups
➢ Contributes to health of the total population
*The terms Public Health Nursing and Community Health Nursing are used interchangeably
in Nies and McEwen, 6th edition.
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25
Community-Based Nursing
“Application of the nursing process in caring for
individuals, families and groups where they live, work
or go to school or as they move through the health
care system”
–McEwen and Pullis, 2009
Setting-specific
Emphasis is on acute and chronic care
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
26
Community and Public Health
Nursing Practice
Nurses practice disease prevention and
health promotion
Practice is collaborative
Practice is based on research and theory
Applies the nursing process to the care of…
➢
Individuals
➢ Families
➢ Aggregates
➢ The community
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
27
Population-Focused Nursing
Focuses on the entire population
Is based on assessment of the population’s
health status
Considers the broad determinants of health
Emphasizes all levels of prevention
Intervenes with communities, systems,
individuals, and families
– Minnesota Department of Health, 2003
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
28
PHN Intervention Wheel
✓ Is population based
✓ Contains three levels
of practice
(individual,
community, and
system)
✓ Identifies 17 public
health interventions
Figure 1-3
Illustration from Minnesota Dept. of Health
Center for Public Health Nursing.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
29
Public Health Interventions
(purple section)
Surveillance: Describes and monitors health events
through ongoing and systematic collection, analysis,
and interpretation of health data for the purpose of
planning, implementing, and evaluating public health
interventions.
Disease and other health event investigation:
Systematically gathers and analyzes data regarding
threats to the health of populations, ascertains the
source of the threat, identifies cases and others at
risk, and determines control measures.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
30
Public Health Interventions
(purple section) (Cont.)
Outreach: Locates populations of interest or
populations at risk and provides information about the
nature of the concern, what can be done about it, and
how services can be obtained.
Screening: Identifies individuals with unrecognized
health risk factors or asymptomatic disease
conditions in populations.
Case finding: Locates individuals and families with
identified risk factors and connects them with
resources.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
31
Public Health Interventions
(green section)
Referral and follow-up: Helps individuals, families,
groups, organizations, and/or communities identify
and access necessary resources to prevent or
resolve problems or concerns.
Case management: Optimizes self-care capabilities
of individuals and families and the capacity of
systems and communities to coordinate and provide
services.
Delegated functions: Direct care tasks a registered
professional nurse carries out under the authority of a
health care practitioner as allowed by law.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
32
Public Health Interventions
(blue section)
Health teaching: Communicates facts, ideas, and
skills that change knowledge, attitudes, values,
beliefs, behaviors, and practices of individuals,
families, systems, and/or communities.
Counseling: Establishes an interpersonal relationship
intended to increase or enhance capacity for selfcare and coping with a community, system, and
family or individual.
Consultation: Seeks information and generates
optional solutions to perceived problems or issues
through interactive problem-solving with a
community, system, and family or individual.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
33
Public Health Interventions
(red section)
Collaboration: Commits two or more persons or
organizations to achieve a common goal through
enhancing the capacity of one or more of the
members to promote and protect health.
Coalition building: Promotes and develops alliances
among organizations or constituencies for a common
purpose.
Community organizing: Helps community groups
identify common problems or goals, mobilize
resources, and develop and implement strategies for
reaching the goals they collectively have set.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
34
Public Health Interventions
(yellow section)
Advocacy: Plead someone’s cause or act on someone’s behalf,
with focus on developing the capacity of the community, system,
and individual or family to plead their own cause or act on their
own behalf.
Social marketing: Uses commercial marketing principles and
technologies for programs designed to influence the knowledge,
attitudes, values, beliefs, behaviors, and practices of the
population of interest.
Policy development and enforcement: Places health issues on
decision-makers’ agendas, acquires a plan of resolution, and
determines needed resources, resulting in laws, rules,
regulations, ordinances, and policies. Policy enforcement
compels others to comply with laws, rules, regulations,
ordinances, and policies.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
35
Providing population-based care… a
shift in thinking
Populations are not homogeneous; must address
the needs of special subpopulations.
2. High-risk and vulnerable subpopulations must be
identified early in the care delivery cycle.
3. Nonusers of services often become high-cost users;
essential to develop outreach strategies.
4. Quality and cost of all health care services are
linked together across the health care continuum.
1.
(Kaiser Family Foundation, 2013)
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
36
Nurses Who Made a Difference…
Florence Nightingale
Sojourner Truth
Clara Barton
Lavinia Dock
Lillian Wald
Mary Breckenridge
Susie Walking Bear Yellowtail
Florence Wald
Ruth Watson Lubic
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
1
Nurses’ Historical and Current
Activity in Health Care Policy
Florence Nightingale
➢
➢
➢
➢
First nurse to exert political
pressure on a government
Transformed military health
Knew the value of data in
influencing policy
Collected and analyzed data
about health services and
outcomes, which now is a
critical element of public
health
Photo credit:
http://commons.wikimedia.org/wiki/Fl
orence_Nightingale
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
2
Nurses’ Historical and Current
Activity in Health Care Policy (Cont.)
Sojourner Truth
➢
Advocate for abolishing
slavery
➢ Supported women’s rights
➢ Helped transform racist and
sexist policies that limited
health and well-being of
blacks and women
➢ Fought for human rights
➢ Lobbied for funds to educate
nurses and physicians
Photo credit:
http://commons.wikimedia.org/wiki/Fi
le:Carte_de_visite.jpg
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
3
Nurses’ Historical and Current
Activity in Health Care Policy (Cont.)
Clara Barton
➢
Organized relief
efforts during U.S.
Civil War
➢ Persuaded Congress
to ratify the Treaty of
Geneva, which
allowed the Red
Cross to perform
humanitarian efforts in
times of peace
Photo credit:
http://commons.wikimedia.org/wiki/File:
WcbbustCBarton.jpg
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
4
Nurses’ Historical and Current
Activity in Health Care Policy (Cont.)
Lavinia Dock
➢
Prolific writer and political
activist
➢ Campaigned to allow nurses
to control the nursing
profession
➢ Advocated for women’s right
to vote
➢ Worked closely with Isabel
Hampton Robb and Mary
Adelaide Nutting to found
forerunner to NLN
Photo credit:
http://commons.wikimedia.org/wiki/File:
Lavinia_Lloyd_Dock.jpg
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
5
Nurses’ Historical and Current
Activity in Health Care Policy (Cont.)
Lillian Wald
➢
Recognized connection
between health and
social conditions
➢ Advocate for
development of the
Children’s Bureau in
1912
➢ Frequently appeared at
White House in
development of national
and international policy
Photo credit:
http://commons.wikimedia.org/wiki/File:Lillian_
Wald_-_William_Valentine_Schevill.jpg
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
6
Nurses’ Historical and Current
Activity in Health Care Policy (Cont.)
Mary Breckenridge
➢
➢
Developed nursing in rural Kentucky
Established Frontier Nursing Service
Photo credit:
http://commons.wikimedia.org/wiki/File:WENDO
VER.jpg
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
7
Nurses’ Historical and Current
Activity in Health Care Policy (Cont.)
Florence Wald
➢
➢
Nursing leader in establishing hospice care in the
United States
Modeled hospice after similar services offered in
United Kingdom
Photo credit:
http://commons.wikimedia.org/wiki/Fil
e:Hospice_Media_Logo.png
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
8
Nurses’ Historical and Current
Activity in Health Care Policy (Cont.)
Susie Walking Bear Yellowtail
➢
➢
Walked from reservation to reservation to improve
health services for Native Americans
Established Native American
Nurses Association
Photo credit:
http://commons.wikimedia.org/wiki/
File:Ketchican_totem_pole_2.jpg
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
9
Nurses’ Historical and Current
Activity in Health Care Policy (Cont.)
Ruth Watson Lubic
➢
➢
Nurse-midwife who
crusaded for
freestanding birth
centers in the United
States
Leader in communitybased birth center
movement
Photo credit:
http://commons.wikimedia.org/wiki/File:Sil
verton_Hospital_birth_center__Silverton,_Oregon.JPG
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
10
Policy is based on values, and the first step in
forming policy is identification of the issue.
Therefore, it would seem rational to define
“health” as the starting point for any policy
annexed to health care issues.
Many Healthy People 2020 objectives directly
or indirectly involve health policy.
– Nies and McEwen, 2015
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
11
Shifts in Philosophy at the CDC
From…
To…
Disease orientation
Health protection focus
Designing and implementing
sponsored programs
Informing and guiding health system
actors
Allocating agency resources
Leveraging resources to steer larger
health system
Emphasis on clinical prevention
Focus on prevention and health
protection
Transaction-based relationships
Partnerships and strategic alliances
Program requirements
Incentives for
participation/cooperation
Collecting and analyzing health
data
Creating integrated health information
systems
Issuing advisories and guidelines Building decision-support system
From Centers for Disease Control and Prevention: State of the CDC: fiscal year 2008, The Author.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
12
Healthy People 2020
Vision
➢
A society in which all people live long, healthy lives.
Overarching Goals
1.
2.
3.
4.
Attain high-quality, longer lives free of preventable disease,
disability, injury, and premature death.
Achieve health equity, eliminate disparities, and improve
the health of all groups.
Create social and physical environments that promote
good health for all.
Promote quality of life, healthy development, and healthy
behaviors across all life stages.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
13
Overview of Health Policy
Public Health Policies
➢
➢
➢
➢
Decisions made at all levels of government (local,
state, or federal)
Influence health care through monitoring,
production, provision, and financing of health care
services
Everyone is affected, from providers to consumers
Influence all health care organizations
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
14
Overview of Health Policy (Cont.)
Public Health System
➢
➢
➢
➢
➢
➢
➢
Authority for public health vested with states
Responsibility delineated by constitution
Compliance with federal program standards is
voluntary but impacted by revenue
Policies influenced by social and political theories
Economics is one factor in decision making
Decisions are slow and deliberate and more
reactive
Needs determined by voting shifts, electoral
realignment, and term limits
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
15
Overview of Health Policy (Cont.)
Private Health Sector
➢
Includes employers, professional organizations,
nonprofit health care organizations, and for-profit
corporations that deliver, insure, or fund health
care services outside of government control
➢ Policies evolve differently—influenced by
economics and business management
➢ Economics is central factor in decision making
➢ Decisions are swift and proactive
➢ Needs determined by consumerism, market
trends, and economics
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
16
Impact of Federal Legislation on
Health Care
Prevention of illness by influencing the
environment
Provision of funding to support programs that
influence health care
Increased the involvement of state and local
governments in health care
Promoted similarities of services in all states
Funding resulted in increased regulations
Standardized U.S. public health policy
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
17
Critical Federal Legislation
Related to Health Care
Pure Food and Drug Act of 1906
➢
Children’s Bureau Act of 1912
➢
➢
Manufacturing, labeling, and sale of food
Regulated unhealthy child labor practices
Shepherd-Towner Act in 1921 extended to infants
Social Security Act of 1935; 1965; 1972
➢
Benefits for mothers, children, elderly, disabled
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
18
Critical Federal Legislation
Related to Health Care (Cont.)
Medicare (Title XVIII) in 1965
➢
Health care services for people over 65, with
permanent disabilities, and those with end-stage
renal disease
Medicaid (Title XIX) in 1965
➢
➢
Combined federal and state program
Access to care for poor and medically needy
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
19
Critical Federal Legislation
Related to Health Care (Cont.)
Public Health Act of 1944
➢
Consolidated all existing public health legislation into one
law
• Health services for migratory workers
• Family planning services
• Health research facilities
• National Institute of Health (NIH)
• Nurse training acts
• Traineeships for graduate students in public health
• Home health services for Alzheimer’s disease patients
• Prevention and primary care services
• Rural health clinics
• Communicable disease control
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
20
Critical Federal Legislation
Related to Health Care (Cont.)
McCarren-Ferguson Act of 1945
➢
Hill-Burton Act of 1946
➢
Gave states right to regulate insurance plans
Federal assistance in construction of hospitals
with stipulations about service for the uninsured
Health Amendments Act of 1956; Title II
➢
➢
Funds for RN education in administration,
supervision, and teaching
1964 Nurses Training Act: funds for loans and
scholarships and to develop more nursing schools
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
21
Critical Federal Legislation
Related to Health Care (Cont.)
Occupational Safety and Health Act of 1970
➢
Focused on health needs and risks in workplace
and environment
Health Maintenance Organization Act of 1973
➢
➢
Employers must offer federally qualified HMOs as
health care option to employees
States had oversight on HMOs
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
22
Critical Federal Legislation
Related to Health Care (Cont.)
National Health Planning and Resources Act
of 1974
➢
Assigned responsibility for health planning to
states and local health system agencies
➢ Required health care facilities to obtain prior
approval for expansion in form of Certificate of
Need (CON)
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
23
Critical Federal Legislation
Related to Health Care (Cont.)
Omnibus Budget and Reconciliation Acts
➢
➢
➢
➢
1981, 1987, 1989, and 1990
Enacted to reduce huge federal deficit
Impacted funding for nursing homes, home health
agencies, and hospitals
Established new guidelines and regulations
including a move from process to outcome
evaluation, use of restraints, and prescription
drugs for Medicaid recipients
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
24
Critical Federal Legislation
Related to Health Care (Cont.)
Tax Equity and Fiscal Responsibility Act of
1982 (TEFRA)
➢
➢
Amendment to SSA of 1935
Established PPS for Medicare, the DRG system
COBRA of 1985
➢
➢
➢
Requires all EDs that participate in Medicare to
provide care for all, regardless of ability to pay
Ensures continuation of insurance after loss of job
Example of how federal government can affect
state health care practices
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
25
Critical Federal Legislation
Related to Health Care (Cont.)
Family Support Act of 1988
➢
➢
Expanded coverage for poor women and children
Expanded Aid to Families with Dependent
Children (AFDC)
Health Objectives Planning Act of 1990
➢
➢
Response to the first Healthy People report (1979)
United States began to identify and monitor
national health goals; Healthy People 2000, 2010,
and 2020
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
26
Critical Federal Legislation
Related to Health Care (Cont.)
Health Insurance Portability and
Accountability Act (HIPAA) of 1996
➢
➢
Ensured portability of insurance coverage
Offered protection for patient privacy and
confidentiality
Welfare Reform Act of 1996
➢
➢
➢
Restricted eligibility for AFDC, Medicaid, etc.
TANF helped move recipients into work; welfare
offered temporary assistance
Many underserved lost Medicaid coverage
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
27
Critical Federal Legislation
Related to Health Care (Cont.)
The State Child Health Improvement Act
(SCHIP) of 1997; 2009
➢
Provides insurance for children and families who
cannot afford health insurance
Medicare Modernization Act of 2003
➢
➢
Most significant law in 40 years for senior health
care
Provides seniors and disabled with some Rx drug
benefit coverage, more choice, and better benefits
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
28
Critical Federal Legislation
Related to Health Care (Cont.)
Nurse Reinvestment Act of 2003
➢
Funding provided to increase enrollments and
number of practicing nurses
Mental Health Parity and Addictions Equity
Act of 2008
➢
Financial requirements (deductibles, co-payments)
and treatment limitations (number of visits; days of
coverage) that apply to mental health benefits
must be no more restrictive than the predominant
financial requirements or treatment limitations that
apply to substantially all medical/surgical benefits
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
29
Critical Federal Legislation
Related to Health Care (Cont.)
Patient Protection and Affordable Care Act
of 2010
➢
All U.S. citizens and legal residents to have
qualifying health coverage
➢ Changes eligibility requirements for Medicaid and
expands CHIPS
➢ Subsidizes premiums for lower and middle income
families
➢ Requires coverage of dependent adult children up
to age 26
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
30
Critical Federal Legislation
Related to Health Care (Cont.)
Patient Protection and Affordable Care Act of
2010 (Cont.)
➢
Significant insurance reforms
• Established high-risk pools
• Covers preexisting conditions
• No lifetime limits on coverage
• Cannot drop policyholders when they get sick
• Must provide preventive care and screenings without
customer cost-sharing
➢
➢
Fosters nonprofit, member-run exchanges
Implemented over several years
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
31
Critical Federal Legislation
Related to Health Care (Cont.)
Patient Protection and Affordable Care Act of
2010 (Cont.)
➢
➢
Funded through new fees and taxes.
• Taxes on indoor tanning
• Medicare taxes for higher income brackets
• Fees for pharmaceutical companies and medical devices
• Penalties for those who do not obtain health insurance
Cost-cutting measures
• Cuts to Medicare Advantage programs
• Reductions in Medicare spending
• Reduce administrative costs, streamline care, reduce
fraud and abuse
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
32
The health reform legislation in 2010 was strongly
influenced by the rising number of uninsured and
underinsured.
The United States is only major developed country to
not have universal health coverage.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
33
State Legislative Role
Focus on financing and delivery of services and
oversight of insurance to address the mission of public
health throughout the state
➢
➢
➢
➢
➢
➢
Assess health needs
Ensure adequate statutory base for health activities
Establish statewide health objectives
Ensure appropriate organized statewide effort to develop
and maintain essential services
Guarantee minimum set of essential health services
Support local service capacity
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
34
Effective Use of Nurses: A Policy
Issue
Title VII funding (HRSA) provides the largest source
of federal funding for nursing education
➢
Nursing shortage is a crisis
➢
➢
➢
Favors education for practice in rural and medically
underserved communities
Economic impact on positions
Focus on hiring BSN graduates (not ADN)
Shortage of nursing faculty
Nurse Education, Expansion, and Development Act
of 2009 amended above to increase funds for nursing
schools
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
35
Nurses’ Roles in Political Activities
The Power of One and Many
…as Change Agents
➢ …with Coalitions
➢ …as Lobbyists
➢ …on Political Action Committees (PACs)
➢ …in Campaigning
➢ …in Voting Strength
➢ …in Public Office
➢
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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