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The Health Care Organization and Patterns of Nursing Care Delivery

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Describe challenges facing health care that affect the delivery of nursing care, including: Reduction of costs Evidence-based care Shortage of health care professionals Patient and workplace safety Delivery changes influenced by the 2010 Institute of Medicine (IOM) Future of Nursing Report Trace the history of the use of nursing care delivery models. Consider ways to structure nursing services to improve care while reducing costs

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cost health care

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-high health expenses national problem-rate of growthh of that spending decreased in late 1990s and early 2000s economics suggest that rate of growth will remain high into foreseeable future

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growth in the cost of health care

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expansion of prescription of drugs and new medical technologies. administrative costs. rise of incidence chronic disease was 75% national health care expenditures

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What do you find most interesting regarding the future challenges of health care? A. Shortage of nurses B. Patient safety C. Cost reduction D. Staffing patterns for nurses E. Affordable Care Act of 2010

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E. Affordable Care Act of 2010

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afforadable care act (ACA)

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was passed providing regulations to reduce cost

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afforadable care act

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Increased governmental regulation of insurers Reduction in payment for treatments and hospitalizations resulting from errors or poor care Funding for research related to comparative effectiveness research Emphasis on patient-centered care Increasing incentives for coordination of care Wider use of technology Increasing consumer out of pocket costs

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what were the important Challenges Currently Facing Health Care?

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Cost of health care Strategy used to reduce costs initially was managed care Shortage of nurses Patient safety

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what is managed care?

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one of the aprroaches designed to reduce costs from ACA while mainting/ improving access and quality

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managed care

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change the fee-for-service

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what was introduced for the prospective payment system that was a reimbursement? (beginning of a movement control health care)

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medicare

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what did medicare help assist?

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insurance companies soon adopted, fixed fee was paid to the hospital according to preset reimbursement rate for diagnosis given at discharge, hospitals can treat patient so short length stay, reducing consumption recourses

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medicare

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A fixed fee was paid to the hospital according to a preset reimbursement rate for the diagnosis given at discharge.

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How Does Managed Care Change Reimbursement Patterns?

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Trend is to pay for health care at a prearranged rate rather than as billed Health maintenance organization (HMO) plans have become very popular as a form of insurance The preferred provider organization (PPO) is another type of insurance plan designed to meet the goals of managed care. Members may use an out-of-network provider, without a referral, if they are willing to pay more for that service

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what is extreme type of managered care?

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capitation

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capiation

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employers pay a set of fee each month to an insurance company for each covered employee and dependent

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HMO (part of managered care trend)

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annual payment is made on behalf of the members to a group of providers who deliver all health services covered under the plan, including doctor and hospital service

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hmo

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they provide strong incentive to avoide hospitilaztion and reduce costs; fewer noncovered services and fewer forms give ease in healthcare

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hmo

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the choice of physician is limited and must be part of this healthcare

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PPO

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preferred provider organization another type of insurance plan designed to meet the goals of managed care; avoids pocket expenses, member must use physicians that agree to provide services lower rate

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PPO

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"out of network referral"

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What Is the Impact of Managed Care on Health Care Entities?

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-Individual hospitals or physicians' offices merging into large-scale organizations -Nonprofit hospitals changing to for-profit status -Work environment likely to involve corporate culture

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what reduced cost of health care?

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managed health care

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why did cost increased sharply in response to backlash from restrictive managed care policies?

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profit was lost, quality of care, and access to services.

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who were the ones that judge the effectivness of care?

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stakeholders ( maneged care organizations, employer, centers for medicare and medicaid (CMS), regulators, providers, indicidual patient

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What Is Meant by Integrated Health Care Delivery Systems?

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Systems offer prevention services, acute- and long-term care facilities, home health care, and hospice services They may offer high degree of continuity of care

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what are case managment society of America

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man

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*health care spending in this country eared 2.6 trillion in 200 more thn ten times the $256 billion spent in 1980

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the kaiser family foundation

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How Does Case Management Support Managed Care?

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-Ensures coordination of care while reducing costs -By assessing, planning, implementing, coordinating, monitoring, and evaluating options and services to meet a person's health needs -Effective in providing care, but not all patients need this intensity of interaction

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What Patient Situations Support the Need for a Case Manager?

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-Have complicated health care needs -Are receiving care that is expensive and complicated -Pose discharge planning problems -Receive care from multiple providers -Are likely to have significant physical or psychosocial problems

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Traditional model ( one of the case managment models)

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Focuses on discharge planning and determining if the care planned throughout the patient's hospital stay is necessary and appropriate (utilization review), so that the insurer will pay for services Case manager reviews the chart every 3 to 7 days and may carry a caseload of between 16 and 28 patients per day.

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Full immersion model ( one of the case managment models)

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Requires the case manager to conduct a daily chart review of the patients and communicate with physicians and nurses caring for the patients on his or her caseload daily

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what happens when there is increased intensity of the workload in the immersion model?

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caseloads are usually 12 to 14 patients on medical and neurology specialty units and 16 to 18 patients on surgical and cardiology units

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Nurse navigator role

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Conceived to reduce patient barriers to care for vulnerable patients who may cope with delays in access, diagnosis, treatment and/or fragmented and uncoordinated care

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a system of coordinated healthcare interventions and communications for populations with conditions inwhich patient self-care efforts are helpful.

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disease managment

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what tools are used to support care coordination? (support care managment)

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cilincal pathways and disease managment protocols

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nurse navigator role areas

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-Disease screening rates, adherence to diagnostic services after identification of an anomaly, and treatment have improved -Identified improved patient satisfaction; positive changes in patient attitudes, understanding of disease process, and perception of a timelier, accessible treatment process

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similar strategies that support work of the coorindator of care to reduce expensive variations in care

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clinical pathways and disease- managment protocols

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clinical pathways?

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Also known as Care Maps, are multidisciplinary plans of the "best" clinical practice for groups of patients with specific medical diagnosis

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Disease management protocols and clinicl pathways?

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Both generally based on clinical guidelines incorporating nationally acceptable ways to are for specific disease

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how do clincial pathways differ pratice guidlines, protocols, and algorithms?

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they are used by interprofessional disciplinary team and have a focus on quaity and coordiation of carefor the individual patients.

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Clinical pathways the 4 essential elements?

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-Timeline outlining when specific care given -Categories of care activities and interventions -Intermediate and long-term outcomes to be achieved -Variance record

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what do Disease management protocols do?

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-Supports physician/patient relationship and plan of care -Emphasizes prevention; uses evidence-based practice guidelines; empowers patients -Evaluates clinical, humanistic, and economic outcomes—goal is to improve overall health

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what is Clinical Guidelines?

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Both critical pathways and disease-management protocols are generally based on clinical guidelines that incorporate nationally acceptable ways to care for a specific disease

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what are the guidlines developed by government agencies?

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-Agency for Healthcare Research and Quality (AHRQ) -American Public Health Association -Centers for Disease Control and Prevention (CDC)

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how do we know that critical pathways and disease- management protocols reflect the latest and best practice?

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In 2000, the Institute of Medicine (IOM) released a report, "Crossing the Quality Chasm: A New Health System for the 21st Century" (IOM, 2000). This report noted that it takes 17 years for the results of research in health care to be transmitted consistently into practice.

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evidence based pratice

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the use of the current best evidence in making decisions about patient care. "what is the best way to manage a particular situation?" * melynk and fineout *

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-Strategy to reduce the amount of time required to integrate new health care findings into practice -Conscientious use of current best evidence in making decisions about patient care -Increasing number of evidence-based nursing centers around the world

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evidence based pratice

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when did the shortage of nurses begin?

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-1998 -nurses are retiring -wider range of career options are now available to young people

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when the united states was in a recission in 2009, Buerhaus and colleagues (2009) found that despite the current easing of the nursing shortage caused by the recession, the U.S. nursing shortage is projected to grow to 260,000 registered nurses by 2025

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shortage of nurses

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shortage of nurses statistics

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-Bureau of Labor Statistics Employment Projections (2010-2012) indicated that the RN workforce is the top occupation in terms of job growth, from 2.74 million jobs in 2010 to an expected 3.45 million jobs in 2025, an increase of 26% -495,500 RNs will retire or leave the workforce, making the total job openings for RNs to 1.2 million by 2020

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What Can Be Done to Recruit Nurses to the Profession?

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-retention of nurses is important as recruitment -interactive advertising -recruitment materials distributed to hospitals, high schools, nursing schools -Improved work environment for nurses

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How can health care organization retain nurses?

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--Adequate compensation --Flexible staffing --Allow professional autonomy --Good communication and interpersonal relationships --Work recognition --Adequate benefits --Professional practice --Follow Magnet hospital programs

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Forces of Magnetism

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- force 1: quality nursing leadership -force 2: organizational structure - force 3: management style - force 4: personnel policies and programs - force 5: professional models of care - force 6: qual. of care force 7: qual improve force 8: consultation and resources force 9: autonomy force 10: relationships between the community and health care organization fprce 11: nurses as teachers force 12: image of nursing

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what were the concern challenges of the us health care system that launched the IOM (impact of the 2010 institute for medicine)?

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high cost, primary care shortages, an aging and sicker population, health care disparities, fragmentation of care.

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Recommendations of the 2010 IOM Future Of Nursing Report

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-Remove scope-of-practice barriers -Expand opportunities for nurses to lead and diffuse collaborative improvement efforts -Implement nurse residency programs Increase the proportion of nurses with a baccalaureate degree to 80% by 2020 -Double the number of nurses with a doctorate by 2020. -Ensure that nurses engage in lifelong learning. -Prepare and enable nurses to lead change to advance health. -Build an infrastructure for the collection and analysis of interprofessional health care workforce data (IOM, 2010).

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The future of nursing report (2010) key messages include:

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- nurses should practice to the full extent of their education and training through an improved education system that promotes seamless academic progression - nurse should be full partners with physciaians for redesigining -effective workforce planning for better data collection

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To improve health care quality, care must be -Safe -Effective -Patient-centered -Timely -Efficient -Equitable

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patient safety

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what do patient safety do?

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-Involve nurse leaders in all levels of management in decision-making. -Improve the effectiveness of communication among caregivers.

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Many nurses prefer this method while being on private duty?

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When one nurse assumes responsibilities for the complete care of a group of patients on a 1:1 basis, providing total patient care during the shift

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IHI

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nonprofit organization focused on improving quality health care

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what do the private duty models do that was suggested by tiedman and lookinland?

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1) decreases communication time between staff caring for a patient 2) reduces the need for supervision 3) allows one person to perform more than one task simultaneously.

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Functional Nursing (movement was used from world war 11)

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-Breaks nursing care into a series of tasks performed by many people -LPN, CNA -Can result in fragmented, impersonal kind of care -Can lead to lack of accountability for the total patient

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evolved as a way to address the problems with the functional approach?

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team nursing

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team nursing duties

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-Groups of patients are assigned to a team headed by a team leader (usually RN) -Success of team nursing centers on good communication among team members -Team conference plays vital role

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determines the work assignments for the team on basis

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team leader

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What is Primary Nursing?

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-Nurse plans and directs care of patient over 24-hour period - reduce fragmentation between shifts

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what do primary nurses do?

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Relationship-based practice is new name for primary nursing—RN manages and coordinates patient's care in hospital and patient's discharge plan

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what is patient focused care?

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- delivery system -Traditional nursing interventions handled by ancillary workers under direction of RN -Moves RNs to higher level of functioning

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In which type of nursing care model would you like to work as a new nurse? A. Primary nursing B. Functional nursing C. Team nursing D. Private duty nursing E. Patient-focused care nursing

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team nursing

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what is a Transitional care model (TCM) ?

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provides comprehensive in-hospital and follow-up care plans.

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what is a Care transitions intervention (CTV)?

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Teaches self-management and communication skills to patients and caregivers so they can coordinate care. -There is also a follow-up component using a home visit and telephone call.

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What are Models of Care for Patient's Transition to Home?

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-tcm -ctv

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What is TeleHealth?

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-Delivery of health-related services and information via telecommunication technology -Can be used in home and community based care, where it typically focuses on chronic disease -Can bring experts to areas that may not have access to such services

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What is the Most Effective Model of Nursing Care?

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-there were 30 models that were researched out of 45 - requirements of the models were : 1) served primary adults patients, 2) rely on nurses to play a primary role in care delivery 3) include an acute care hospital component, 4) intergrate technology, support systems, new roles, 5) improve quality, efficiency, and costs

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what were the models that were evaluated included what common elements?

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-RN serves as "primary care manager" -More focus on patient -Greater patient and family involvement → faster recovery and compliance -Specialized tools for assessment -Integration of technology to enhance communication and reduce wasted time -Reliable indicators to measure satisfaction

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What is the Impact of Staffing Patterns on Quality of Care?

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-Lower levels of hospital nursing staffing associated with more adverse outcomes -Patients in hospitals today more acutely ill than in the past, yet skill levels of nursing staff have declined -Higher acuity patients have added responsibilities, increasing nurse workloads -Avoidable adverse outcomes, such as pneumonia, can raise treatment costs -Hiring more RNs does not decrease profit

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What is the Impact of Staffing Patterns on Quality of Care?

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-Higher RN nurse staffing was associated with less hospital-related mortality, failure to rescue, and other patient outcomes, but the higher RN staff might not be the cause of these outcomes, because hospitals that invest in adequate nursing staff may also invest in other initiatives to improve quality (AHRQ, 2007). -Greater RN hours spent on direct patient care were associated with decreased risk of hospital-related death and shorter lengths of stay (AHRQ, 2007).

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How Are Nursing Work Assignments Determined?

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-Vary with individual institutions -Patient acuity fluctuates dramatically from day to day and from season to season -Can be based on budgeted nursing hours per patient per day -Establish a hospital-specific written staffing plan. Identify and mandate fixed staffing ratios.

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What About Scheduling Patterns?

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-10-hour days, 4 days a week -Two 12-hour weekend shifts for 36 hours of pay (the Baylor Plan) -Use of overtime can cause job stress, accidents, absenteeism, poor job productivity -Mandatory overtime should only be used in emergency situations

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A nurse wants to work in a setting in which it is possible to have a dramatic impact on the cost of health care. What type of setting would this nurse probably choose to work in?

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Chronic disease clinic

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The student of health care policy understands that pay-for-service models prevalent in the early 1990s contributed to rising health care costs through which mechanism?

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Providers charged whatever they wanted.

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A nurse is caring for four patients. Which would the nurse refer to case management?

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76 years old; receiving chemotherapy and wound care at home

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A nurse on the unit Research Council is looking for articles to support a change in practice. Which reference(s) would provide the highest level of evidence for this change?

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One well-designed randomized controlled trial

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A nurse looking for a job wants a workplace in which the nurse has 24-hour responsibility for patient care for a specific group of patients and wants to develop meaningful relationships with patients and families. Which nursing pattern of nursing care should this nurse look for?

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Primary nursing

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