The Healthcare Delivery System (The Nature of Nursing) Part 1

Learning Objectives

1.    Discuss trends and challenges of healthcare in the 21st century. Relate these changes to the needs of nurses, healthcare practitioners, and the consumers of healthcare (clients).

2.    Define and discuss differences between acute care and extended care facilities, and identify the types of healthcare services provided in each type of healthcare facility.

3.    Identify at least three services available to meet the healthcare needs of the community.

4.    State at least two functions of a school nurse and an industrial nurse.

5.    State at least two functions of The Joint Commission. Relate these functions to nursing standards of care.

6.    Define the term quality assurance and state its function in healthcare facilities.

7.    Explain the role of the client representative, advocate, or ombudsperson.

8.    Describe at least six methods of payment for healthcare services.

9.    Determine the role of complementary or holistic care in the delivery of healthcare.

10.   Identify at least three negative impacts of consumer fraud on public wellness.



holistic healthcare

outcome-based care

capitation fee

home healthcare


case management


prospective payment


incentive programs

quality assurance


Joint Commission

respite care



managed care



third-party payment



















This topic primarily addresses nursing in the context of a healthcare facility that cares for the very ill, or a facility that has services that provide long-term or extended care. Throughout the topic you will note references to specific nursing situations, such as geriatrics, pediatrics, or home health.

Your school of nursing may provide clinical experiences in acute care and long-term care, as well as supplemental clinical experiences in ambulatory care settings such as clinics or home care. Field trips to specialty areas may be available (e.g., dialysis units, burn units, or rehabilitation centers).

This topic discusses concepts related to basic healthcare service in the United States. The student and the consumer need to be aware of different types of healthcare facilities and payment plans, as well as the common types of healthcare services. Healthcare providers must be aware of the general concepts of the various aspects of healthcare service because the consumer (i.e., client) often relies on providers as preliminary reference sources. In other words, we are often asked where to go for further information, what to do next when a situation occurs, or how to obtain assistance.

Your student nursing experiences are individual and unique. It is the responsibility of the student to achieve the maximal benefits from each experience.

Key Concept Remember:The principles of excellent nursing care are universal.


Healthcare continues to change dramatically. Changes include an emphasis on wellness and individuals assuming more responsibility for their own health. Technology will continue to influence healthcare in direct and indirect ways. The cost of healthcare technology also remains a major consideration. The use of technology in healthcare will provide new avenues of diagnosis, treatment, and nursing care.

Before the 1980s, healthcare was primarily the concern of physicians who treated patients during times of illness. Preventive care, such as diabetic screening or cardiac assessment, was not considered until after a problem developed. Enormous amounts of money are needed to care for patients with existing health problems. Often, preventative healthcare problems interrelate and magnify health problems. Obesity, for example, very often is found in clients with diabetes, cardiac complications, visual problems, and acute and chronic infections. Additionally, the quality of life for individuals who have substandard health has immediate as well as long-term consequences. Prevention and early treatment literally affect a variety of serious issues, such as the quality of life, financial obligations, and family dynamics.

Research into the rising costs of healthcare revealed that many patient and financial needs could be met by preventive care. Patients needed better health education with ongoing screening and monitoring of illness. Additionally, the focus of many aspects of health and healthcare could and should be the responsibility of the patient.

Preventive care can literally prevent health problems before they develop. The benefits of preventative care for infants, children, and adolescents should be strongly encouraged by the healthcare professional. Preventative intervention includes a variety of methods, such as the use of well-baby clinics, encouraging the wearing of safety-gear, or monitoring nutrition and weight. The benefits of remaining healthy are also extremely cost effective. The trend continues to evolve to prevent illness and accidents, as often as possible, before they occur.

Starting in the 1980s, the concept of managed care or case management was implemented to halt rapidly rising medical costs and to increase efficiency in care delivery. Managed care is a plan for continual monitoring and maintenance of an individual’s health. It promotes wellness-focused care and preventive medicine. Although the patient, who is often referred to as a consumer or a client, remains an individual, the managed care organization can standardize goals for clients with similar disorders. The client can be treated on an individual case-by-case basis, but a group of individuals with the same disorder can have similar goals or plans.

Key Concept Because healthcare recipients are involved in the management of their own health, they are often referred to as clients, rather than patients. Client implies active participation in the choice of the (healthcare) service. The client makes decisions regarding health in the same manner as any consumer who makes choices or decisions based on their existing level of knowledge, the type of resources available, the comments or referrals from others, and their personal, past experiences.

The term patient implies a relatively passive acceptance of health services and providers, or cases in which the individual is unable to make decisions about his or her own care.

In this text, the term client is used.

Managed care plans are called many names including critical pathways, care maps, clinical pathways, or standard nursing care plans. These plans identify desired outcomes and timelines. Healthcare professionals must follow such plans to receive full reimbursement for services from third-party payers.

Health maintenance organizations (HMOs) are examples of managed care systems. HMOs emphasize disease prevention and health promotion. Their goal is to avoid health problems by preventing conditions that could become more serious (and more costly). Clients are often treated on an outpatient basis, and hospitalizations are minimized. HMOs will be discussed in more detail later in this topic.

Trends that differentiate HMOs from “traditional” healthcare have evolved. In the 21st century, healthcare may involve discussion among the healthcare practitioner (e.g., physician), an insurance provider who agrees to pay for the treatment or therapy, and the client.

The role of the nurse is being redefined to meet the challenges of managed care and reimbursement regulations. In some cases, unlicensed assistive personnel (UAPs) are being hired to administer nursing care. This practice is becoming more common across the country and is often a subject of controversy. The standards of education for UAPs are generally much less stringent than the educational requirements for a licensed nurse.

As a result of financial constraints and the influence of managed care plans, clients may have treatment outside a hospital, such as in a wound-care treatment center or a rehabilitation center. Clients can be admitted to the hospital, have a surgical procedure performed, and be discharged the same day.

To be admitted to an acute care facility, the client must meet a minimal level or need for healthcare services known as acuity. Clients admitted to acute care facilities have high levels of acuity. Thus, the person receiving care in the hospital is often more critically ill than such clients have been in the past. Hospitalizations are of shorter duration and—as a result—the client is often discharged while he or she still needs healthcare services.

As a result of specific changes in the delivery of healthcare services, extended care facilities (ECFs) and home healthcare services have restructured to meet the intermediate acuity needs of clients. In the recent past, ECFs were exclusively the “nursing home” or long-term care facility for the aging adult. Twenty-first century clients may be transitioned or transferred from one level of care (acuity) to another level of care. For example, a client may be discharged from an acute care hospital to be admitted into an extended care facility. At the ECF, the client may receive physical therapy and rehabilitation before being discharged to home. A client may be monitored at home by a home-health nurse. Employment for nurses in all of these areas is projected to increase in the future.

The myriad of changes in healthcare will continue to alter the role of nurses in the 21st century, whether they practice in acute/subacute, extended, community-based, or home care settings (which are discussed later in this topic). Challenges of the 21st century include disparities in access to healthcare, inequities in access to healthcare insurance, and continued high-risk behaviors, such as smoking.

As the healthcare system and methods of payment develop and change in this century, so will nurses’ responsibilities and the facilities in which they work. Nurses must continue to be involved in planning for future healthcare service. Teamwork will remain important, but the methods of collaboration will change. For example, the increasing use of UAPs as care partners and increasing responsibilities for licensed practical nurses will undoubtedly have profound effects on the delivery of healthcare.

Nursing plays a significant role in the attainment of client care outcomes. As a nurse, you will need to understand and articulate the value of well-educated staff for the delivery of healthcare in the 21st century.


Acute Care Facilities

Acute Care Hospitals

Acute care hospitals are the most commonly known healthcare facility. Acute care implies that a client in the hospital has a serious condition that needs to be closely monitored by healthcare professionals, particularly nurses. Acute care facilities admit clients for short periods of time, usually only a matter of a few days. Clients are often very sick and need a great deal of nursing care. Box 3-1 summarizes services that are commonly found in acute care facilities.

Intensive Care Units

Intensive care units (ICUs) that care for the critically ill are found in acute care facilities. ICUs may specialize in medical, surgical, respiratory, coronary, burn, neonatal, and pediatric care areas. ICUs provide care for clients by specially trained nurses. Many ICUs use high-tech equipment and health status monitors.

Subacute Care Facilities

Many hospitals have areas that are classified as subacute care or step-down units. A person may move to a subacute unit when the level of acuity of care has decreased. However, the client is not considered ready for discharge. A client may be transferred from an ICU to a step-down unit before being discharged from the hospital.

BOX 3-1. Services Commonly Found in an Acute Care Facility




Admitting and Discharge


Ambulatory Care/Outpatient Surgery




Emergency Care


Home Health


Intensive Care Unit




Medical Unit








Physical Therapy




Respiratory Therapy


Surgical Unit


Telemetry Unit


Transitional Care/Step-Down Units

Outpatient Care Centers

Most general hospitals provide “same-day” surgery, also known as outpatient or ambulatory care centers. In the past, nearly all surgical procedures required hospital admission. Economic issues forced the increase of surgeries performed on an outpatient basis. The client can return home the same day to recuperate. Outpatient treatment centers have become very popular because they save the client time and money. Day-surgery centers built by physician groups often compete with an acute care facility’s outpatient department.

NCLEX Alert Clinical scenarios describe care in different types of healthcare environments such as acute care, long-term care, rehabilitative care, or home-based hospice. To select the correct option on an NCLEX. you may need to know what type of care is needed and select the agency that will best serve the client.

Specialized Hospitals

Specialized hospitals are facilities that admit only one type of client. Examples include government veteran hospitals, psychiatric, or pediatric hospitals. Specialized hospitals may also have units for medical, surgical, or intensive care. Other types of specialized hospitals include facilities for the developmentally or mentally disabled. Some facilities care for specific conditions, such as head and spinal cord injuries or substance abuse.

Although its primary function is to provide healthcare, the hospital performs other functions. For example, your clinical facility has the added role of education, and many large hospitals, particularly those affiliated with a university, also play an important role in research.

With acute care facilities sending individuals home earlier to recover from surgery or illness, the need for home healthcare has increased. In some cases, nursing care is available 24 hours a day in the home. However, in most cases, the family and other lay caregivers need to take responsibility for some care. Nurses are vital in teaching individuals how to perform care in the home.

Taking time to teach clients about their medication and treatment program promotes interest and cooperation. Older adults who are actively involved in learning about their medication and treatment program and the expected effects may be more likely to adhere to the therapeutic regimen.

FIGURE 3-1 · Taking time to teach clients about their medication and treatment program promotes interest and cooperation. Older adults who are actively involved in learning about their medication and treatment program and the expected effects may be more likely to adhere to the therapeutic regimen.

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