Chapter

5 Healthcare Delivery
Systems
Introduction

Health care system is the totality of services provided by all health

disciplines.
The major purpose of a health care system is to provide care to people
who were ill or injured.

However, with increasing awareness of health promotion, illness

prevention, and levels of wellness, health care systems are changing,
as are the roles of nurses in these areas. The services provided by a health
care system are commonly categorized according to type and level.
Types of Healthcare Services

Primary prevention
 Health education and promotion
 Disease prevention

Secondary prevention
￭ Diagnosis (imaging tests, screenings, biopsies), treatment

Tertiary prevention
￭ Rehabilitation, health restoration, palliative care
￭ Goal: To help patients move to their optimum capabilities given
their current health status
Primary Prevention: Health Promotion and Illness
Prevention
• Health promotion (proper nutrition, exercise), illness prevention
(stress reduction, weight control) to maintain the highest level of health.

• Healthy People 2030 goals

⚬ Increase quality and years of healthy life
⚬ Achieve health equity and eliminate health disparities
⚬ Create healthy environment for everyone
⚬ Promote health and quality life across the life span
⚬ Engage leadership, key constituents, and public to design policies that
improve health and well-being

Emphasizes the important role clients play in maintaining

their own health and encourage them to maintain the highest
level of wellness they can achieve
Secondary Prevention: Diagnosis and
Treatment
In secondary prevention, disease is detected and treated early, often before
symptoms are present, thus minimizing serious consequences. Types of
secondary prevention include the following: Screening programs, such as
mammography to detect breast cancer and dual x-ray absorptiometry (DXA) to
detect osteoporosis.

• Hospitals
⚬ Emergency care
⚬ Intensive care
⚬ Around-the-clock care

• Health promotion services

⚬ Early detection
⚬ Routine screening
 Tertiary Prevention: Rehabilitation, Health
Restoration, and Palliative Care
Its goal is restoration to previous level of health or highest level possible, given
current health status and seeks to reduce the impact of established disease by
eliminating or reducing disability, minimizing suffering, and maximizing potential
years of quality life.

• Rehabilitation to function adequately in the physical, mental, social,

economic, and vocational areas of their lives
• Outreach programs for mental health illness
• Palliative care
⚬ Providing comfort and treatment
⚬ End-of-life care conducted in many settings including the home

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 TYPES OF
HEALTHCARE
AGENCIES AND
SERVICES
Public Health

Local health departments develop programs to meet the health needs of the
people, providing necessary nursing and staff to carry out these programs,
continue evaluating the effectiveness of the program, and monitoring changing
needs.

• Public Health Service (PHS) of the U.S. Department of Health and Human
Services
• National Institutes of Health (NIH)
• Centers for Disease Control and Prevention (CDC)

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Physicians' Offices

• Family practice physicians, specialists

• Routine health screening, illness diagnosis, and treatment

• NPs more common than RNs in this setting

Ambulatory Care Centers

• Diagnostic treatment facilities

• Minor surgeries can be performed
• Out-patient Department
• Clinics

They permit the client to live at home while obtaining necessary health care,
and they free up costly hospital beds for seriously ill clients.
Occupational Health Clinics

Republic Act No. 11058: An Act Strengthening Compliance with

Occupational Safety and Health (OSH) Standards and Providing Penalties for
Violations Thereof; was mandated to employ an occupational nurse to promote
safety and health to employees of companies with more than 50 but fewer than
200 employees.

• Run by companies for employees

• Health promotion activities
Hospitals

Hospitals vary in size from the 12-bed rural hospital to the 1,500-bed
metropolitan hospital. Hospitals can be classified according to their ownership
or control as governmental (public) or nongovernmental (private).
• Acute inpatient services
• Outpatient and ambulatory care
• Emergency department
• Hospice care

Classifications:
• General
• Specialty (e.g., Psychiatric, Orthopedic, Pediatric, etc.)
 Hospitals
Primary Hospital
these facilities typically serve as the first point of contact between the members of their
community and the medical system
e.g., Infirmaries, community hospitals

Secondary Hospital
caters patients with more complex health conditions or those who need more
extensive medical support.
e.g., District Hospitals

Tertiary Hospital
it is a hospital that provides tertiary care, which is a level of health care obtained from
specialists in a large hospital after referral from the providers of primary care and
secondary care.
e.g., Provincial Hospitals, Regional Hospitals, General Hospitals
Subacute Care Facilities

Subacute care is a variation of inpatient care designed for someone who has an
acute illness, injury, or exacerbation of a disease process.
• . Subacute care is generally more intensive than long-term care and less
intensive than acute care.
Extended (Long-Term) Care
Facilities
These facilities provide levels of personal care for individuals who cannot
manage daily living independently and requires ongoing supervision due to
chronic illness, disability, or aging.
• Services Offered:
⚬ Medical and nursing care.
⚬ Assistance with activities of daily living (ADLs), e.g., bathing,
hygiene, and eating.
⚬ Social and recreational activities.

• Duration: Typically months to years; not intended for short-term

recovery.
• Examples: Nursing homes, skilled nursing facilities (SNFs).
Retirement and Assisted Living
Centers
These centers cater to older adults who are largely independent and
doesn’t need full-time medical care but require some assistance with daily tasks
to promote independence while offering a safety net for essential needs.

• Services Offered:
⚬ Housing and meals.
⚬ Personal care assistance
⚬ Social activities and community engagement opportunities.

• Examples: Retirement communities, senior apartments with

assistance options.
Rehabilitation Centers

These facilities are designed to help patients recover and regain

function after illness, injury, or surgery.

• Physical rehabilitation
⚬ Post-surgery, stroke, or injury recovery.
• Occupational therapy
⚬ Restoring skills for daily activities.
• Speech therapy
⚬ Helping patients regain communication or swallowing abilities.

• Interdisciplinary Approach: Teams often include physical therapists,

occupational therapists, and speech-language pathologists.
Home Healthcare Agencies

These agencies deliver medical and supportive care to patients in their own
homes; often elderly, post-surgical patients, or those with chronic
illnesses.

• Services Offered:
• Skilled nursing care (e.g., wound care, IV therapy).
• Personal care (e.g., bathing, grooming).
• Rehabilitation services (e.g., physical therapy at home).
• Health education for patients and families.

Goal: Promote patient independence while minimizing hospital

readmissions.

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 Day Care Centers

These facilities offer care for individuals needing

supervision or specialized services during the
day.

• Elderly adults: Socialization and health monitoring.

• Special needs individuals: Developmental or medical
care.

• Services Offered:
⚬ Health monitoring (e.g., medication
administration).
⚬ Therapeutic activities to maintain physical and
cognitive function.
⚬ Meals and transportation services.
 Rural Care

Rural healthcare facilities cater to populations in remote or less densely

populated areas where access to healthcare services is often limited.

• Emphasis on preventive, primary, and some secondary care

services.
• Limited availability of advanced technology, specialists, and healthcare
professionals.

• Community Health Programs:

⚬ Mobile health units, telemedicine services, and community outreach.
⚬ Relies on public funding or non-governmental organizations to operate
effectively.
 Hospice Services
Hospice care is specialized for patients with terminal illnesses, focusing on
comfort rather than cure.

• Palliative and Holistic Care Approach:

⚬ Relief from pain and other distressing symptoms.
⚬ Addresses physical, emotional, social, and spiritual needs of patients and
families.
• Interdisciplinary Team:
⚬ Includes doctors, nurses, social workers, chaplains, and volunteers.
• End-of-Life Care:
⚬ Supports patients in their final stages of life, often in the home or
dedicated facilities.
• Family Involvement:
⚬ Offers counseling and bereavement services for loved ones.
Crisis Centers

Crisis centers provide immediate intervention for individuals facing urgent

psychological, emotional, or social crises.

• Emergency Support:
⚬ Accessible 24/7 for mental health emergencies, domestic violence, or
substance abuse crises.
⚬ Ensure privacy and anonymity for clients seeking help.
⚬ Focus on stabilizing individuals and connecting them to ongoing care.

• Community Integration:
⚬ Collaborates with law enforcement, social services, and healthcare
providers.
⚬ Offer crisis hotlines and proactive community education programs.
 Mutual Support and Self-Help
Groups
These are peer-led groups where individuals share experiences and support each
other in coping with specific health or life challenges.

• Peer-Led Structure:
⚬ Facilitated by members with lived experiences rather than professionals.
⚬ Participants find validation and encouragement by connecting with others
facing similar issues.
• Voluntary Participation:
⚬ Members join and contribute at their own pace.
• Empowerment and Growth:
⚬ Focus on fostering resilience, recovery, and self-efficacy.

• e.g., Alcoholics Anonymous (AA), Narcotics Anonymous (NA), cancer

survivor support groups.
TYPES OF NURSES
 Registered Nurse
(RN)
A registered nurse (RN) is a nurse who has graduated or successfully passed
a nursing program from a recognized nursing school and met the requirements
outlined by a government-authorized licensing body to obtain a
nursing license. An RN's scope of practice is determined by legislation, and is
regulated by a professional body or council.

Responsibilities:
• Assessing patients' conditions and developing care plans.
• Administering medications and treatments.
• Performing diagnostic tests and analyzing results.
• Supervising LPNs, LVNs, and NAs.
• Educating patients and families about health conditions and prevention.
• Advocating for patients and ensuring quality care.
 Licensed Practical/Vocational Nurse
(LPN/LVN)
Licensed practical nurses provide basic nursing care under the direction and
supervision of Physicians, RNs or other health team members.

Responsibilities:
• Monitoring patients' vital signs.
• Providing basic wound care and dressing changes.
• Assisting with activities of daily living (ADLs).
• Administering medications (except IV in some states).
• Reporting changes in patients’ conditions to RNs or physicians.
• Collecting samples for testing (e.g., blood or urine).
 Nursing Assistant/Aide
(NA)
Nursing assistants provide basic care and help patients with activities of
daily living, orderlies transport patients and clean treatment areas. Their
focus is direct patient care and non-clinical tasks.

Responsibilities:
• Assisting with personal hygiene (bathing, grooming, toileting).
• Helping patients with mobility and transfers.
• Measuring vital signs (temperature, pulse, blood pressure).
• Reporting patient complaints or unusual conditions to nurses.
• Ensuring patients’ rooms are clean and organized.
 Key differences in
responsibilities
ROLE PRIMARY FOCUS

RN Assess, Diagnose, Plan, Implement, and Evaluate patient care

LPN Basic nursing care, monitoring, and reporting.

NA Non-clinical tasks and essential patient support.

Alternative (Complementary) Care
Provider
There are a wide range in practices, but typically these services focus on
creating health through balance between mind, body, spirit, and environment.

Traditional Healers
• Midwives/Hilot
• Albularyo
• Babaylan

Alternative Therapies
• Acupuncture
• Acupressure
• Chiropractic manipulation
• Aromatherapy
 Case Manager

Case managers ensure that clients receive fiscally sound, appropriate care in
the best setting. This role is often filled by the member of the health care team
who is most involved in the client’s care.

Depending on the nature of the client’s concerns, the case manager may be a
nurse, a social worker, an occupational therapist, a physical
therapist, or any other member of the health care team.
 Dentist

• Dentists diagnose and treat mouth,

jaw, and dental problems. Dentists
(and their dental hygienists) are
also actively involved in preventive
measures to maintain healthy oral
structures (e.g., teeth and gums).
 Dietitian or Nutritionist

Dietitians are concerned with therapeutic

diets, supervise the preparation of meals to
ensure that clients receive the proper diet,
and may design special diets to meet the
nutritional needs of individual clients.

Nutritionists recommends healthy diets and

provides broad advisory services about the
purchase and preparation of foods.

DIETITIANS AND NUTRITIONISTS

FUNCTION ON A PREVENTIVE LEVEL
 Emergency Medical Personnel

• Titles, education, and certification

vary for emergency medical
technicians (EMTs) and paramedics.
These personnel are trained to
assess, treat, and transport
clients experiencing a medical
emergency, accident, or trauma.
Occupational Therapist

An occupational therapist (OT)

assists clients with impaired
function to gain the skills to
perform activities of daily living
(ADLs)
 Paramedical Technologist

Laboratory Technologist
• examine specimens such as urine, feces, blood, and discharges from
wounds to provide exact information that facilitates the medical diagnosis
and the prescription of a therapeutic regimen

Radiologic Technologist
• assists with a wide variety of x-ray film procedures, from simple chest
radiography to more complex fluoroscopy.

Nuclear Medicine Technologist

• uses radioactive substances to provide diagnostic information and can
administer radioactive materials as part of a therapeutic regimen.
 Pharmacist

Pharmacists prepares and dispenses

pharmaceuticals in hospital and community
settings.

A clinical pharmacist is a specialist who

guides primary care providers in prescribing
medications.
Physical Therapist
The licensed physical therapist (PT)
assists clients with musculoskeletal
problems. Physical therapists treat
movement dysfunctions by means of heat,
water, exercise, massage, and electric
current.

Responsibilities:
• Assessing client mobility and strength
• Providing therapeutic measures (e.g.,
exercises and heat applications to
improve mobility and strength)
• Teaching new skills (e.g., walking with
an artificial leg).
 Physician
The physician is responsible for medical
diagnosis and for determining the therapy
required by a person who has a disease or
injury. They are the primary healthcare
providers of the clients.

Primary Care Practitioners / General

Practitioners / Family Doctors
⚬ Provide the first point of contact for
most clients

Specialist Physicians
⚬ Specializes on the care of specific
group of clients. (e.g., Oncology,
Gynecology, Internal medicine,
Orthopedics)
Physician Assistant

PAs performs certain tasks under direction of physician and may have similar
job description to NP

Responsibilities:
• Making rounds and performing patient exams.
• Diagnosing illnesses.
• Assisting in surgery.
• Ordering and interpreting laboratory tests and X-rays.
• Prescribing medications.
Podiatrist

Doctors of podiatric medicine (DPM) diagnose and treat foot and ankle
conditions. They are licensed to perform surgery and prescribe medications.
Respiratory Therapist

These therapists are knowledgeable

about oxygen therapy devices,
respirators, mechanical ventilators, and
accessory devices used in inhalation
therapy.

Respiratory therapists administer many

of the pulmonary function tests such as
spirometry.
Social Worker

A social worker counsels clients and their support persons regarding problems
such as finances, marital difficulties, and adoption of children.

They are particularly familiar with both public and private resources available to
clients according to their socioeconomic qualifications.
Spiritual Support Personnel

Chaplains, pastors, rabbis,

priests, and other religious or spiritual
advisers serve as part of the health care
team by attending to the spiritual needs of
clients
Unlicensed Assistive Personnel

• Assumes delegated aspects of basic client care

⚬ Bathing, assisting with feeding, collecting specimens, and transport of
client.
Factors
Affecting
Healthcare
Formerly, people expected a primary care provider to make decisions about their

Delivery
care; today, however, consumers expect to be involved in making any decisions.
Consumers have also become aware of how lifestyle affects health. As a result, they
desire more information and services related to health promotion and illness
prevention.

A number of other factors affect the ability of the health care delivery system to meet
the needs of the population.
 Increasing Number of Older Adults

• By 2035, over 78 million adults over 65

⚬ Exceeds population under 18 for the
first time

• Substantial home management, nursing

support services required

• Older adults also need to feel they are

part of a community even though they are
approaching the end of their lives. The
feeling of being a useful, wanted, and
productive citizen is essential to every
person’s health.
Advances in Technology

Scientific knowledge and technology related to health care are rapidly

increasing. Improved diagnostic procedures and sophisticated equipment permit
early recognition of diseases that might otherwise have remained undetected

New procedures, medications, technology

⚬ (e.g., telehealth/telemedicine, health tracking/wearables
Bedside charting and computers

Cons
Costly
Issues in client privacy and confidentiality
Economics

• Health spending predicted to reach $5.7 trillion by 2026

• Cost increases, mostly in equipment replacements and prescriptions
Women's Health

• Until recently, it is only focused on reproductive aspects of health such as

birthing facilities

• Current provision for women’s health are intended for research that
examines women equally to men such as osteoporosis, heart disease, and
responses to treatment modalities
⚬ Increased emphasis on psychosocial aspects of women's health
including the impact of career, delayed childbearing, role of caregiver to
older family members, and extended life span.
Uneven Distribution of Services

• Increased specialization
⚬ Fragmentation, higher cost of care depending on the geographical
location
• Remote, rural locations
⚬ Clients need to travel long distances to obtain services they require.
Access to Health Insurance

Without health insurance, people receive less preventive care, delay or avoid
care and medications, are diagnosed later in their illnesses, and have higher
mortality. In addition, because of low or absent reimbursement for services,
primary care providers may hesitate to provide care.

• Those without insurance diagnosed later in illnesses

• Those with greatest need for care often least able to pay for it
The Homeless and the Poor

n to health care facilities, especially if repeated visits are necessary. Limited

access to health care services significantly contributes to the general poor
health of people who are homeless and poor.

• General poor health exacerbated due to the environment they dwell in.
• Lack of convenient, timely transportation and support group
Health Insurance Portability and
Accountability Act

The HIPAA (Act of 1996) regulations were instituted to protect the privacy
of individuals by safeguarding individually identifiable health care records,
including those housed in electronic media. The clients are notified a notice of
privacy practices.

Accomplished by:
• restricting access to only those individuals who truly need to possess the
information to aid the client, by locking documents in file cabinets, and by
limiting access to computerized health care files
Demographic Changes

• Increasing alternative family structures

• Cultural and ethnic diversity
Nursing Modalities /
Frameworks of Care
A number of configurations for the delivery of nursing
care support continuity of care and cost effectiveness
has been developed over the years to accommodate
the need to decrease costs, improve limited
physical resources, and improve patient
care
Managed Care

Managed care describes a health care system whose goals are to provide cost-
effective, quality care that focuses on decreased costs and improved outcomes
for groups of clients by collaborating to render the most appropriate, fiscally
responsible care possible.

Managed Care Nurses serve as the liaison between patients, doctors,

healthcare providers and insurance companies. In contrast to direct patient care
at the bedside, their role is to advocate for all patients enrolled in the healthcare
delivery system.
Case Method/Total Patient Care
The nurse provides total care for one
patient during their entire shift. 1:1
Nurse-Patient ratio

• Focused on holistic, patient-

centered care.
• One nurse is responsible for
meeting all patient needs during
their assigned time.
• Promotes continuity of care
and strong nurse-patient
relationships.

COMMONLY USED IN
CRITICAL CARE UNITS OR
PRIVATE DUTY NURSING
Functional Nursing Method

Team members focuses on jobs to be

completed and tasks are divided among
team members based on their roles or
skills.
• Work is assigned in a task-
oriented approach (e.g., one
nurse administers medications,
another handles hygiene).
• Often used during times of staff
shortages or in emergency situations.
• Clear delegation of responsibilities
ensures tasks are completed promptly.

USED IN EMERGENCY
DEPARTMENT
Team Nursing

A group of nurses and other healthcare staff work collaboratively to care for a
group of patients. (RNs, LPNs, NAs, UAPs.)

• A team leader (RN) supervises and coordinates the team.

• Delegates care tasks based on team members' roles and competencies.
• Emphasizes collaboration and effective communication within the team.

COMMONLY USED IN GENERAL WARD

Primary Nursing

It is a 24-hr continuous coordinated comprehensive nursing

service of 5-6 patients from admission to discharge. It is the oldest form
of nursing care modality.

1:5-6 Nurse-Patient ratio

Primary Nurse
⚬ Responsible in making nursing care plans and nursing procedures.

Associate Nurse
⚬ Takes over in patient care after primary nurse’s shift. They cannot
change the NCP, except there are changes in patient’s condition,
provided that it is reported to the primary nurse.
Modular Nursing

It is a combination of team and primary

nursing but with a geographic
assignment of patients. It is used on
disaster response or nursing shortage.
 Case Management

Utilizes healthcare delivery system to deliver

quality care, to promote the quality of life, to
decrease fragmentation, and to contain cost. It
focuses on long term treatment.
⚬ Occupational, art, music
therapy

USED IN NURSING HOMES and

HOSPICE CARE
Financing Healthcare
Cost containment efforts include health promotion/illness prevention activities,
managed care, alternative insurance systems.

• Affordable Care Act (ACA)

⚬ It is controversial and very complex since individuals will be fined if they
do not have health insurance.
• Expanded Medicaid eligibility
⚬ American Health Benefit Exchanges
⚬ Small Business Health Options Program
⚬ Extended coverage for children in modified private plans
⚬ Nonprofit Patient-Centered Outcomes Research Institute
⚬ National Prevention, Health Promotion, Public Health Councils
Payment Sources in the United
States
• Healthcare agencies receive funding from several
available sources.
⚬ Medicare
⚬ Medicaid
⚬ Private insurance
⚬ Out-of-pocket
￭ Copayment
 Payment Sources in the United
States

Medicare - Medicare is a U.S.

government health insurance program that
subsidizes healthcare services.
• For adults over 65
⚬ Part A provides hospitalization,
home care, hospice.
⚬ Part B provides partial outpatient
and physician services (voluntary).
⚬ Part D prescription plan
(voluntary) Coinsurance and
deductible Does not cover dental,
eyeglasses, hearing aids, etc.
 Payment Sources in the United
States
Medicaid - is a joint federal and state
program that helps cover medical costs for
some people with limited income and
resources.
￭ Federal financial assistance
• Those with low incomes
￭ Each state is distinct.

Supplemental Security Income

⚬ Benefits people with disabilities
and older adults with little to no
income
⚬ For those not eligible for Social
Security
Payment Sources in the United
States
• Children's Health Insurance Program (CHIP) - provides low-cost
health coverage to children in families that earn too much money to qualify
for Medicaid.
⚬ Insurance coverage for poor and working class children
⚬ Includes primary care, prescriptions, hospitalization
Payment Sources in the United
States
Women, Infants, and Children Program
⚬ Nutritional foods to supplement diets
⚬ Information on healthy eating
⚬ Referrals to healthcare
￭ Mothers and children up to age 5

Prospective Payment System

⚬ Limits amount paid to hospitals that are reimbursed by Medicare
⚬ Diagnosis-related groups (DRGs)
Insurance Plans

• Private Insurance
⚬ Not-for-profit and for-profit
⚬ Most often pay 80% of costs
⚬ Third-party reimbursement - the insurance company that pays
the client’s (first party) bill to the provider (second party).
 Insurance Plans
Group Plans - provide coverage to a group of members, usually comprised
of company employees or members of an organization in exchange for monthly
payment.

• Health maintenance organizations (HMOs) - It is a health

insurance organization to which subscribers pay a predetermined fee in
return for a range of medical services from physicians and healthcare
workers registered with the organization.
￭ Emphasizes client wellness
￭ Limited selection of providers, services
￭ Reduced, predetermined costs

• Accountable care organizations (ACOs)

￭ Provider reimbursements tied to quality metrics, reductions in total
cost of care
Insurance Plans
• Preferred provider organizations (PPOs)
￭ Choice of healthcare providers, services
￭ Tend to be more expensive than HMOs

• Preferred provider arrangements (PPAs)

￭ Can be contracted with individual healthcare providers
￭ Can be limited or unlimited

Independent practice associations (IPAs)

￭ Clients pay fixed prospective payment to IPA and IPA pays provider.

Physician/hospital organizations (PHOs)

￭ Primary care providers and specialists
￭ May be part of integrated delivery system (IDS)
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