GAO (2001b). Adults with mental disorders are also more likely to lose health insurance coverage within a year following their diagnosis than those without a mental disorder (Sturm and Wells, 2000). 5, The Health Care Delivery System. Three levels of Health Care Primary Secondary Tertiary Primary Care Goal: To decrease the risk to a client (individual or community) of disease or dysfunction. Lasker and colleagues observed, [t]he dominant, highly respected medical sector focused on individual patients, emphasizing technologically sophisticated diagnosis and treatment and biological mechanisms of disease. Using delivery system innovations to advance health care reform continues to be of widespread interest. Context 1. . The current shortage of RNs, particularly for hospital practice, is a matter of national concern because nursing care is critical to the operation and quality of care in hospitals (Aiken et al., 1994, 2001). NCVHS (National Committee on Vital and Health Statistics). Increase the proportion of underrepresented U.S. racial and ethnic minorities among health professionals. 1999. Billings and colleagues (1993) demonstrated strong links between hospital admission rates for such conditions and the socioeconomic and insurance status of the population in an area. Insurance protects the buyers of health coverage against catastrophic risks. Patients regularly spent significant portions of their admission on gurneys in a hallway. Additionally, the media may be a powerful tool for familiarizing the public with health and health care issues and a conduit for raising important questions, stimulating public interest, or even influencing the public's health behaviors. Phase 1. Having a regular source of care improves chances of receiving personal preventive care and screening services and improves the management of chronic disease. The EIP sites have performed investigations of meningococcal and streptococcal diseases and have established surveillance for unexplained deaths and severe illnesses as an attempt to identify diseases and infectious agents, known and unknown, that can lead to severe illness or death (CDC, 2002). Furthermore, when the delivery of health care through the private sector falters, the responsibility for providing some level of basic health care services to the poor and other special populations falls to governmental public health agencies as one of their essential public health services, as discussed in Chapter 1. Such plans are characterized by higher per capita resource constraints and stricter limits on covered services (Phillips et al., 2000). Furthermore, changes in the funding streams or reimbursement policies for any of these programs or increases in demand for free or subsidized care that inevitably occur in periods of economic downturn create crises for safety-net providers, including those operated by state and local governments (see the section Collaboration with Governmental Public Health Agencies later in this chapter for additional discussion). Health care's structure and incentives are technology and procedure driven and do not support time for the inquiry and reflection, communication, and external relationship building typically needed for effective disease prevention and health promotion. Although cardiovascular disease is the leading cause of death and diabetes is one of the most significant chronic diseases affecting Medicare beneficiaries, physicians cannot screen for lipids disorders or diabetes unless the patient agrees to pay out-of-pocket for the tests. 1988. The medical screening rate is not adjusted according to the federal periodicity schedule or the average period of eligibility, but instead reports the percentage of children who were eligible for any period of time during fiscal year 1996 and who received one or more medical screens. Although evidence has not established that increasing the numbers of minority physicians or improving cultural competence per se influences patient outcomes, existing research supports clear policies to increase the proportion of medical students drawn from minority groups. Coverage of clinical preventive services has increased steadily over the past decade. Why does cost containment remain an elusive goal in U.S. health services delivery? The majority, however, work in hospitals, although the proportion dropped from 68 percent in 1968 to 59 percent in 2000 (Spratley et al., 2000). Furthermore, nurses have available other professional opportunities, and women, who once formed the bulk of the nursing workforce, now have alternate career prospects. Institute of Medicine (US) Committee on Assuring the Health of the Public in the 21st Century. 1997. Denver Health is the local (county and city) public health authority, as well as a managed care organization and hospital service. The rapid development and widespread implementation of an extensive set of standards for technology and information exchange among providers, governmental public health agencies, and individuals are critical. With start-up funding from a local foundation, its own fundraising, and annual corporate sponsorships ranging from $35,000 to $150,000 from local hospitals and businesses, the coalition launched a Safe Communities initiative with a 52-member community advisory panel. Values, practices, relationships, laws, and investment and reimbursement policies must support the creation and use of data and information systems that are consistent with the vision for the NHII (see Chapter 3 for an additional discussion and recommendation). The health care and governmental public health sectors are also very unequal in terms of their resources, prestige, and influence on public policy. (2002); CMS (2002a); CMS (2002c). The demonstrations should be supported by adequate resources to enable innovative ideas to be fairly tested. What are some delivery systems? 2002, Medicaid and Other State Healthcare Issues: The Current Situation, NASBO analysis: Medicaid to stress state budgets severely into fiscal 2003, Early release of selected estimates based on data from the JanuaryJune 2001 National Health Interview Survey, Information for Health: A Strategy for Building the National Health Information Infrastructure, Nurse Staffing and Patient Outcomes in Hospitals. Manic-depressive illness is reported to exist in 1 percent of adults. That report emphasized that untreated health problems can affect children's physical and emotional growth, development, and overall health and well-being. Medicare's pilot project IdeaTelInformatics for Diabetes Education and Telemedicineoffers web-based home systems to rural and inner-city diabetics to support home monitoring, customized information, and secure links to providers and to the patients' own medical records (www.dmi.columbia.edu/ideatel/info.html). What are the four basic components of all health care delivery systems? See also pregnancy. To ensure healthy patients, you must have healthy health care systems. However, the committee finds that both the scale of the problem and the strong evidence of adverse health effects from being uninsured or underinsured make a compelling case that the health of the American people as a whole is compromised by the absence of insurance coverage for so many. Taken alone, the growth in Medicaid managed care enrollment; the retrenchment or elimination of key direct and indirect subsidies that providers have relied upon to help finance uncompensated care; and the continued growth in the number of uninsured people would make it difficult for many safety net providers to survive. Smith et al. Although these various individuals and organizations are generally referred to collectively as the health care delivery system, the phrase suggests an order, integration, and accountability that do not exist. Although these reductions may have improved the efficiencies of hospitals, they have important implications for the capacity of the health care system to respond to public health emergencies. In the aggregate, these per capita expenditures account for 13.2 percent of the U.S. gross domestic product, about $1.3 trillion (Levit et al., 2002). For example, admission rates for asthma were 6.4 percent higher in low-income areas than in higher-income areas, with more than 70 percent of the variation explained by household income (Billings et al., 1993). Ready access to necessary clinical expertise. Findings from Coverage Matters. . Lurie N, Ward NB, Shapiro MF, Gallego C, Vaghaiwalla R, Brook RH. Channeling purchasing power into community business, Housing development through capital leverage, Minority Graduates of US Medical Schools: Trends, 19501998, Emergency departmentsan essential access point to care, The health care workforce shortage and its implication for America's hospitals, Depression in Primary Care: Treatment of Major Depression, Nurses' report on hospital care in five countries, Lower Medicare mortality among a set of hospitals known for good nursing care, Dental insurance is essential, but not enough, Socioeconomic characteristics of medical practice 1997/ 98, Emergency departments and crowding in United States teaching hospitals, Unmet health needs of uninsured adults in the United States, Journal of the American Medical Association, Health insurance and access to care for symptomatic conditions, Beyond the Medical Model: Hospitals Improve Community Building, Community Care Network (CCN) Briefings, Fall 2001, Reducing the frequency of errors in medicine using information technology, Journal of the American Medical Informatics Association, Effect of computerized physician order entry and a team intervention on prevention of serious medication errors, The status of local health care safety-nets, Assessing Core Capacity for Infectious Diseases Surveillance, Final Report prepared for the Office of the Assistant Secretary for Planning and Evaluation. Cost sharing is an effective means to reduce the use of health care for trivial or self-limited conditions. The provision of such services is cost-effective and comparable to the cost-effectiveness of other common procedures. coordination in healthcare is imperative. Promote the consistency and equity of care through the use of evidence-based guidelines. However, the basic functional components include running the system, the different branches of the system, how services are rendered, how the services are funded, and manufacturing of new products (Barton, 2010, p. 6-8). Committing leadership at multiple levels through the top leadership to sustain changes; Developing community partnerships to develop champions outside the organization; Protecting funding and leadership of community health initiatives while integrating community health values into the culture of the parent organization; Linking community work with clinical work (mission alignment); Building an evidence base through evaluation and ongoing measurement of community health indicators; and.