HEALTH CARE DELIVERY MODELS Medical/Biomedical Model Public Health Model Primary Care Models Chronic Care Model Patient Centered Care Model Medical Home Model Public Health Model • Goal: Focus on health of populations rather than individuals • Considers broad determinants of health • Concerned with health promotion & disease prevention throughout society • All 3 levels of prevention • Primary, secondary, tertiary • All levels of practice • Individual/Family, Community, & Systems What is Public Health? • Definitions vary • What we, as a society, do collectively to assure conditions for people to be healthy (IOM, 1988) • Revised in THE FUTURE OF THE PUBLIC’S HEALTH IN THE 21ST CENTURY (IOM, 2002) • WHO-Ideal state of physical & mental health • Using evidence-based interventions to help most vulnerable improve their health & quality of life • Government-sponsored activities that support the health of the population through education/promotion, resource development, surveillance, clinical services What is Public Health? • Core functions of public health: assessment, policy development, & assurance • 10 essential services through the broad public health system; policy development should be driven through shared leadership; translation of policy into practice; implementation of evidencebased science into interventions • Although primary care & public health share goal of promoting health & well-being of all people, these two disciplines historically have operated independently of one another Public Health Core Functions & 10 Essential Services Medicine vs. Public Health Workforce • Medicine • Physicians, nurses, dentists, therapists, social workers, psychologists, nutritionists, health educators, pharmacists, laboratory, administrators • Public Health • Same as above, but also includes sanitarians, epidemiologists, statisticians, hygienists, environmental health specialists, toxicologists, & economists Public Health vs. Population Health • Per CDC (2019): Public health works to protect and improve the health of communities through policy recommendations, health education and outreach, and research for disease detection and injury prevention. It can be defined as what “we as a society do collectively to assure the conditions in which people can be healthy” (Institute of Medicine, 1988). On the other hand, population health provides “an opportunity for health care systems, agencies and organizations to work together in order to improve the health outcomes of the communities they serve” Public Health vs. Population Health • Institute of Medicine’s (National Academy of Medicine) The Future of the Public’s Health in the 21st Century • Building a new generation of intersectoral partnerships that draw on the perspectives & resources of diverse communities & actively engage them in health action • Some say Public Health = Health of the Public = Population Health Epidemiological Explanation of Disease Occurrence Epidemiology Model • Host • Agent • Environment • Based on biostatistics • Science of public health Risk Factors • Risk- probability a disease or negative health condition will develop • Directly influenced either positively or negatively by environment, genetics, lifestyle, & access to quality health care • Negative influences = risk factors • Attributes increasing likelihood of developing disease or negative health condition • Are the public health problems we see today the responsibility of family vs. society? OTHER HEALTH CARE DELIVERY MODELS Chronic Care Model • “Tyranny of the urgent” • Structure & processes allow primary care practices to provide more organized & integrated care for patients with chronic diseases • Team approach directed by clinicians • Supports informed, active patient selfmanagement • Improved patient outcomes & reduced costs Patient Centered Health Care • IOM (2001): "Providing care that is respectful of and responsive to individual patient preferences, needs, and values, ensuring that patient values guide all clinical decisions." • The Affordable Care Act defined "Nurse Managed Health Clinic" (NMHC) in the Public Health Service Act (Section 330) for the first time • Created a new $50 million grant program for nurse-managed primary care & wellness centers that serve vulnerable & underserved populations Patient-Centered Care (QSEN) 6 dimensions of patient-centered care: • Respect for pts’ values, preferences, & expressed needs • Coordination & integration of care through collaboration & teamwork • Accessibility & free flow of information, communication, & education • Physical comfort • Sensitivity to non-medical & the spiritual dimension of care: emotional support • Involvement of family & friend • “At the heart of the environment of care, however, are the human interactions that occur within the physical structure to calm, comfort, & support those who inhabit it” (Drenkard, 2013) Patient-Centered Health Care • Grounded in mutually beneficial partnerships among health care providers, patients, & families • FNPs recognize vital role families play in ensuring health & well-being of family members of all ages acknowledging emotional, social, & developmental support are integral components of health care • Away from disease-centered model Patient-Centered Model • Services focus on the individual’s needs & preferences • Patients & families actively participate in care & make choices about care as part of health care team • Collaborate with health care professionals in making clinical decisions • Puts responsibility for important aspects of selfcare & monitoring in patients' s (family) hands • Better outcomes & better self-management Patient-Centered Model: QSEN • Patient Centered Care in Action • Patients on healthcare organization Advisory Councils • Open hours/appointment slots • Patients involved in care • Interactive web-based education • Family orientation to care experience • Ongoing patient/family surveys to provide feedback • Patient friendly rights and responsibilities • Family information & resource centers • Healing environment • Medical/healthcare homes Patient-Centered Model: QSEN • Patient Centered Care in Action • Use “Ask Me” questions in all clinical interviews • Apply a clinical checklist to improve effective communication, cultural competence, & patient/family centered care across the care continuum • Identify & work to eliminate barriers to include family in care • Serve as a role model & mentor in clinical experiences to reflect cultural competence, patient/family engagement, & positive patient experience Patient Centered Medical Home (PCMH) • NCQA (2104): PCMH model emphasizes care coordination & communication to transform primary care into “what patients want it to be” • ARHQ (n.d.): Model organized to encompass 5 core functions of primary healthcare so that care is comprehensive, patientcentered, coordinated, accessible, & provides quality & safety Accountable Care Organizations (ACOs) • Groups of physicians, hospitals, & other health care providers, who together give coordinated high quality care to pts. • Goal of coordinated care is to ensure pts., especially the chronically ill, get right care at right time, avoiding unnecessary duplication of services • Goal to prevent medical errors Accountable Care Organizations (ACOs) • ACOs designed to address fragmented, disconnected nature of fee-for-service health care delivery in most parts of US & ways in which it rewards quantity instead quality (results & outcomes) • ACOs have increasingly connected with Triple Aim (Porter & Kaplan, 2015) Primary Objectives of Health Care Systems • Enable all citizens to receive health care services • Improve access to underserved areas & populations • Deliver services that are cost-effective & meet established standards of quality Relevant Trends • Aging population • Racial/ethnic diversification of the population • Technology advances • Evolving models of care • Growing recognition of the importance of preparedness for and response to public health emergencies • Increasing awareness of racism & health equity issues Beliefs, Values & Health • Is there equity in health care in US? • Beliefs & values in US have remained mostly constant (private) • No universal health care financed by taxes • No entitlement • There has been little or no: • Networking or interprofessional collaboration • Standardization or coordination of care • Cost containment as a whole • Planning or direction US Health Care System • Unique system of delivery • Market-based health insurance system • Health care crisis • Social determinants influence who becomes ill & who receives access to quality health care • Barriers to accessing care, medical debt & the shortage of PCPs affect all people U.S. Health in International Perspective: Shorter Lives, Poorer Health (IOM , 2013) • US spends more on health than many other industrialized countries • U.S. population experiences poorer health & ranks behind most countries • US ranks low on key indicators among 17 developed countries: • Life expectancy, mortality from disease, infant mortality • Many factors influence poor U.S. health outcomes • Quality • Access • Efficiency • Equity The U.S. Health Care System • Prior to January 2014: • 200.9 million Americans with private insurance • 43 million Medicare beneficiaries • 42.6 million Medicaid recipients • 46.3 million (15.4%) uninsured • Managed Care- HMOs & PPOs • SCHIP The Uninsured • Decreasing number of uninsured was key goal of Affordable Care Act- provided Medicaid coverage to many low-income individuals in states that expanded coverage & Marketplace subsidies for individuals below 400% of the poverty line • Most are poor, low-income working families • Adults more likely to be employed but uninsured • Lack of access to primary care is a large reason for US’s lag in population health (i.e. infant mortality, life expectancy) Access to Health Care • 4 Factors affect access • Ability to pay • Availability of services (delivery) • Payment • Enablement barriers Patient Protection & Affordable Care Act of 2010 (PPACA) • ACA does not focus solely on physician provided medical care to individual patients. Instead the statute is suffused with provisions that promise to elevate the status of, & national commitment to, disease prevention, wellness promotion, & population based interventions (Deville & Novick, 2011, p. 102) PPACA • Current organization of health care in US not patient centered but physician oriented • ACA provided funding for primary care, preventive care, & PCMH • January 2014 an additional 30- 47 million uninsured Americans accessed insurance • Projected shortage of over 90,000 physicians by 2020 • Aging population living longer with chronic illness adds even more instability to problem PPACA • No denying coverage due to pre-existing conditions for children under 19 • Prohibits placing lifetime limits except fraud or nonpayment • Prohibits federal payments for conditions acquired in health care facilities • Covers all preventive care recommended by US Preventive Services Task Force • Promotes standardization of care • Initiate pay-for performance for cost-effective quality care • Increases payments to PCPs PPACA • Reduces drug prices • Bans dropping high-cost customers or charging more • Required to offer coverage to children under 26 • Improves dental benefits for children • Limits waiting periods for coverage • Promotes EBP • Maintains portability of insurance • Financial assistance available for those at 138-400% of FPL • Increases Medicaid eligibility (138% FPL) for all those under 65 Health Information Technology & Meaningful Use • General Meaningful Use objectives established at the national level • Includes ability to electronically generate & transmit prescriptions & generate reminders for patients of upcoming appointments • Meaningful Use objectives relevant to public health include the capability to submit electronic data for immunizations, reportable laboratory results, cancer, & syndromic surveillance IHI Triple Aim (IHI, 2016) • Framework that describes approach to optimizing health system performance • Need new designs to simultaneously pursue three dimensions or the Triple Aim • Improving the patient experience of care including improved quality & patient satisfaction • Improving the health of populations (Better patient outcomes) • Reducing per capita cost of health care • Quadruple Aim adds provider satisfaction IHI Triple Aim (IHI, 2016) • Important to: • Harness array of community determinants of health • Empower individuals & families • Broaden role & impact of primary care & other community based services • Assure seamless journey through entire system of care throughout an individual’s life NP Opposition AAFP (2012): Primary Care for the 21st Century’ in 2012 insists that physicians, not NPs, should lead primary care practices because NPs have: 1. Insufficient rigor of education: 11 yrs. vs.
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