1.5 Health-Care Delivery Systems

Inpatient Services

Hospitals provide inpatient services for patients who are acutely ill, experiencing complications from a disease, or undergoing or recovering from a surgical procedure. Additionally, some hospitals provide specialized care. For example, there are children’s hospitals, hospitals with cardiac care units, cancer centers, burn units, and many other specialty centers. Even hospitals that provide the same inpatient services may be structured in a variety of ways. Some hospitals are-for profit entities, whereas others also have a nonprofit component. Additionally, states designate certain hospitals as providers of care for the area’s low-income population (indigent care).

Subacute inpatient settings are for patients who still need skilled care but are no longer sick enough to remain in the hospital. This type of care is provided in skilled nursing facilities (sometimes called nursing homes), as well as in specialty hospitals for patients who require certain services, such as those receiving ventilatory support. Another type of subacute setting is independent rehabilitation centers, which may be housed within hospitals or nursing homes. There are also specialized rehabilitation centers for conditions such as brain injuries and in Veterans Administration hospitals, where military veterans may be recovering from spinal cord injuries or learning to live with blindness.

Outpatient Services

Many people who live at home still need outpatient, or ambulatory, care. This care, which provides employment opportunities for many health-care workers outside of hospitals, includes diagnostic, observation, treatment, and rehabilitation services. Examples of outpatient services include

• acute care clinics
• centers for chemotherapy and radiation treatment
• dialysis centers
• imaging centers for computed tomography scans, magnetic resonance imagining, ultrasounds, mammograms, and other types of scans
• laboratories for processing outpatient blood samples
• outpatient surgery centers
• settings for physical and occupational therapy
• wound care centers

Post-Acute Services

Patients who are well enough not to require inpatient care as they recover from an acute condition may benefit from a variety of post-acute services in the community. The goal of post-acute care is to increase a person’s ability to care for themselves and to promote as much independence as possible. Outpatient post-acute services are offered by many providers and include the following:

• Assisted living facilities provide medical oversight for medically frail persons who can no longer live safely at home.
• Home health agencies provide skilled care as well as physical and occupation therapy for patients in their home.
• Hospice agencies support patients with a prognosis of 6 months or less to live.
• Infusion therapy agencies deliver intravenous medications or fluids to patients who need them.
• Memory care facilities assist individuals at risk of wandering, such as those with diagnoses such as Alzheimer disease and other types of dementia.
• Personal care and group homes provide medical oversight in a residential, family-type environment and tend to be less expensive than traditional assisted living facilities. For low-income individuals, Medicaid waivers can assist with this expense.
• Rehabilitation centers provide physical and occupational therapy to improve strength and mobility for people recovering from illness, injury, or stroke.

Adult Care Services

Every community includes people who require assistance to stay in their homes. Community-based services that can provide this help include in-home care and adult day care.

In-home care is different from home health care. In-home agencies provide a care assistant: some are certified nursing assistants and personal care aides, others are individually trained by the agency they work for. These aides help with bathing, dressing, grooming, and light household chores and errands. The care is supervised by a nurse in the agency, but no skilled care is involved. Aside from private pay, different types of funding are available that vary from state to state through Medicaid and associated waiver programs. Additional programs are available for individuals with developmental disabilities, veterans, and other special populations. The Area Agency on Aging is a good resource for seniors to find and gain access to community services.

Adult day care centers provide respite for caregivers, enabling them to continue working or otherwise live their life while their loved one is being cared for. Unlike traditional senior centers, where relatively healthy individuals can socialize, exercise, and take classes, adult day care centers are for individuals who have physical and cognitive conditions that require supervision and a higher level of need. Research has shown that these services have a positive impact not only on patients but also their caregivers (Kiger, 2017; Ellen et al., 2017).

Public Health

Public health agencies, through government funding, shoulder much of the responsibility of providing care to the underserved, the uninsured, and other at-risk populations. The goal of public health is the prevention of premature death and disability through measurable improvements in health status and quality of life. To ensure success, political figures may need to be better trained in public health so that legislation and policies go beyond the science to also consider how economic, ideological, and personal factors can affect the needs of people in the public health system.

The decision-making process within political systems at the national, state, and local levels is the vehicle through which public health initiatives and delivery systems are funded. Health is a key determinant of economic vitality, but it is dependent on the effectiveness of health-care delivery systems. To sustain economic vitality and development, the workforce requires affordable health care as well as affordable housing, transportation, and other social and economic determinants. Thus, the outcomes related to public health are directly related to and reliant on the decisions of elected officials, many of whom do not necessarily see how their decisions affect the delivery of public health. Facilitating constructive dialog between public health advocates and legislators could lead to sustainable improvements to public health policies and programs.

Primary Prevention

The goal of primary prevention is to prevent disease before it occurs. This can be accomplished by making lifestyle changes to correct unhealthy choices or unsafe behaviors, preventing exposure to environmental hazards, and taking measures to increase resistance to disease or injury. Strategies for primary prevention include

• becoming more knowledgeable about the signs and symptoms of and risk factors for relevant diseases or illnesses within one’s family, such as diabetes, high blood pressure, stroke, and pulmonary and heart-related diseases
• choosing to be immunized against infectious diseases
• choosing to eat healthier foods
• making better, more informed choices regarding exercise, diet, and other behaviors
• supporting enforcement to mandate safe practices such as wearing seatbelts
• supporting legislation to control the use of hazardous environmental products

Vaccination programs to prevent infectious diseases, public health campaigns promoting healthy lifestyles and behaviors, and education on the importance of regular exercise and a balanced diet all fall under primary prevention. Community health centers, schools, workplaces, and public health departments are common physical locations for primary prevention efforts.

Secondary Prevention

The goal of secondary prevention is to promote early diagnosis and treatment to slow the progression of a disease or injury and reduce its long-term impacts. This process begins with early detection and incorporates strategies such as:

• modifying work for injured or ill workers to enable them to return to work safely
• regularly screening for cancers (e.g., mammograms to screen for breast cancer; oral screenings to detect mouth cancers)
• screening for high blood pressure
• taking low doses of aspirin daily to prevent a stroke

Secondary prevention often occurs in health-care facilities and clinical settings. Examples include hospitals, clinics, diagnostic centers, and physician offices, where screenings, health check-ups, and early detection activities are conducted.

Tertiary Prevention

The goal of tertiary prevention is to decrease the impact of an ongoing illness or injury (e.g., educating people about how to manage their long-term condition). Effective tertiary treatment can help patients regain mobility and bodily function and maintain a positive quality of life. Examples include

• chronic disease management programs (e.g., diabetes, depression) to slow the disease’s progress and develop modifications to promote quality of life
• palliative care to reduce and relieve symptoms of chronic illness
• stroke rehabilitation programs
• vocational rehabilitation programs to retrain injured or ill workers for new jobs

Tertiary prevention is frequently implemented in rehabilitation and specialized care facilities. Hospitals with rehabilitation units, outpatient rehabilitation centers, and chronic disease management clinics are common physical locations for tertiary prevention efforts. Support groups and counseling services may also be located in community centers or health-care institutions.

Patient Demographics

Population demographics directly influence the need for health care and its delivery. In fact, the effectiveness of traditional health-care delivery in the United States has been greatly affected by changing demographics, necessitating innovative changes throughout the health-care delivery system (Vespa et al., 2020). Not only is the US population increasing but its composition is changing due to a variety of factors, including immigration and social trends. Other factors that affect patient demographics are birth and death rates, socioeconomic status, cultural diversity, the relative sizes of different age groups, the number of people living in urban versus rural communities, and the number of homeless people versus the number of families in an area. Table 1.7 summarizes some of the main ways that US demographics are changing.

Beyond 2030, the US population is projected to grow slowly, to age considerably, and to become more racially and ethnically diverse.

Access to Health Care and Insurance

Although access to health care is an important determinant of health, having health insurance is even more important. Health insurance is an essential factor to accessing routine health care, especially preventive care, and it is directly correlated with better health outcomes. It ensures a regular source of care with the most appropriate use of health services, which, in turn, improves access to disease screening, early detection, and care for chronic and acute conditions.

People without health insurance are at an increased risk of going without health care. This is particularly damaging for children, because lack of access to health care promotes poor health and decreased productivity throughout their lives and increases the risk of premature death.

Advances in Technology

Many advances in technology have resulted in changes within the health-care delivery system. The introduction and spread of telehealth, sometimes called e-health or m-health (mobile health), has enabled patients to access health-care services remotely, though personal computers, tablets, or smartphones, rather than in person. Telehealth has been exceptionally helpful in remote areas where access to health-care facilities is limited. Goals of telehealth include

• facilitating patients’ self-management of their care
• improving communication and coordination of care among all members of the health-care team
• keeping people safe from infectious diseases such as COVID-19
• making access to health care easier for those with limited mobility or transportation
• offering primary care and specialist care simultaneously (e.g., through an online conference call or meeting)

Additionally, through a range of innovations such as remote monitoring, patient portals, personal health apps, and accessible personal health records, technology has brought about much-needed changes in the health delivery system to improve patient outcomes (Nursing informatics n.d.). Rapid, reliable communication is one of the most important aspects contributing to patient safety, and the aforementioned innovations have greatly improved turnaround times for physician orders and enabled everyone on the care team to access EHRs more quickly, resulting in reduced medical errors, fewer delays to patient care, and lower costs of health care.

Triple-Aim Initiative

The IHI has developed a framework intended to optimize the performance of health-care delivery systems by pursuing three dimensions simultaneously: (1) improving the patient experience of care, (2) improving the health of the population, and (3) improving health equity by reducing the per capita cost of health care.

IHI calls this initiative “Triple Aim.” Triple Aim recognizes that chronic health problems resulting from an aging population with increased longevity have become a global challenge and created new demands on medical and social services. Though it broadly focuses on health at the community level, Triple Aim requires systemic, ambitious improvement at all levels of the system (IHI, n.d.).

The IHI believes communities and organizations that successfully implement Triple Aim will have healthier populations because they will identify problems and solutions upstream, before they require acute health-care services; this will alleviate the need for complex care coordination and decrease the burden of illness. Furthermore, stabilizing or even reducing the per capita cost of care will allow private providers to be more competitive, relieving the pressure on publicly funded health-care budgets and giving communities greater flexibility to invest in SDOH such as schools and the environments where people live and work.