Chapter 11: The Health Care System & Public Health

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Welcome back to the Deep Dive.

We are back at it and today we have a massive mission ahead of us.

We are looking at a stack of material that honestly it feels a little bit like looking at the blueprints for a nuclear submarine.

That is a good way to put it.

It's complex, it is dense, and it's absolutely critical for our listeners.

It is and specifically we are talking to the nursing students out there.

If you're listening to this maybe you're on a long drive, maybe you're at the gym, or maybe you are just you know trying to survive your community health rotation.

Yes.

We are unpacking chapter 11 the health care system from the text community public health nursing.

And we are doing this with a very specific goal.

We want to turn this chapter which can feel very

dry and bureaucratic into a survival guide because let's be real you're not just studying a textbook.

Not at all.

You're studying the machine you are about to spend your entire career inside of.

That is the perfect analogy.

The machine and the authors of this text they make clear right from the first page.

This is a unique machine.

Unique is one word for it.

The U .S.

health care system isn't really comparable to any other system in the world.

And when they say unique they don't necessarily mean that in a you know we're number one everything is perfect kind of way do they?

No not exactly.

It's a mix of high praise and very harsh criticism.

On one hand we are the global leaders in technology.

If you have a complex rare condition that requires a cutting edge procedure the United States is exactly where you want to be.

Right.

We have the best toys.

We have the best toys so to speak.

On the flip side.

On the flip side the system is criticized heavily for high costs.

I mean astronomical costs.

Really insignificant issues with quality and access.

It's a paradox.

It really is.

We have the best care in the world but millions and millions of people can't get to it or it bankrupts them if they do.

So our mission today is to decode this paradox.

We're going to walk through the chapter exactly as it's written.

We're going to look at the structure.

The private versus the public side.

We're going to look at the providers.

That alphabet soup of acronyms you have to memorize.

Oh the alphabet soup.

And we are going to look at the critical issues.

The things that are keeping hospital administrators and frankly bedside nurses awake at night.

And we're doing this because you, the future nurse, you need to know how to navigate this.

When you're standing at a bedside you are not just checking vitals.

No.

You're the navigator.

You are the navigator for your patient.

And if you don't understand how the machine works, who pays for what, where the resources are, what the rules are, you cannot advocate for them effectively.

It's impossible.

So let's open the blueprints.

The chapter centers around a big overview.

Specifically figure 11 .1 in the text.

It divides the entire U .S.

health care system into two major subsystems.

Right.

So imagine a chart split right down the middle.

On the left side you've got the private subsystem.

On the right side you have the public health subsystem.

Okay.

Let's start with the private side.

What defines that world?

What's its focus?

The private subsystem is what most Americans think of when they hear health care.

Its focus is on the individual.

The single patient.

The single patient.

Whether it's a non -profit hospital like a university hospital or a for -profit clinic,

the mission is generally the same.

To provide personal care services to the person who is standing right in front of them.

And the public health subsystem on the other side of that line?

The focus there shifts completely.

It moves from the individual to the population.

So not one person but the whole city.

The whole city.

The whole state.

This includes federal programs, state programs, and local health departments.

Their patient isn't a single person with a broken leg.

Their patient is the entire community.

And their job is different.

Totally different.

They focus on prevention, disease control, environmental safety, you know making sure the water is safe to drink.

Now looking at this fire, are these two worlds totally separate?

Like is there a big wall between them?

You might think so given how different they feel sometimes.

But the text makes a really important point to say they are not mutually exclusive.

Their functions overlap constantly.

How so?

Give me an example.

Okay so a private hospital has to follow public health regulations for reporting infectious diseases.

Right like COVID or tuberculosis.

Exactly.

And a public health clinic which is population focused might treat an individual for an STD to stop an outbreak.

So it's not a hard line.

It's a very blurry line.

They're distinct but they are deeply intertwined.

And running underneath both of these subsystems there is this tension.

The text calls them driving forces.

Yes.

The core conflicts.

And the two big heavyweights that are always battling it out are cost effectiveness and quality care.

It's the eternal struggle isn't it?

We want it to be cheap and we want it to be perfect.

Exactly.

And often the measures you take to save money like say cutting staff or limiting the number of tests you can order can directly conflict with the quality of care.

It's a balancing act that never really truly stabilizes.

And we absolutely have to mention the piece of legislation that just shook this whole foundation up in the last decade or so.

The ACA.

The Patient Protection and Affordable Care Act of 2010.

The text highlights this as a pivotal moment.

The ACA demonstrated the critical importance of access to health care for all Americans.

It tried to bridge that massive gap we talked about earlier.

But it wasn't exactly smooth sailing was it?

Oh not at all.

Yeah.

The text notes that while it over a decade in and still trying to figure out how to implement it fully and what its final form will be.

Right.

And connected to this the Institute of Medicine, the IOM, they issued a call back in 2012.

They basically said we need to use science and information technology to improve efficiency.

In other words.

In other words they said the system is too expensive and it's too messy use data to fix it.

Which is you know easier said than done.

Okay so that's the high level overview.

We have the two subsystems private and public and they're constantly wrestling with this tension between cost and quality.

Let's zoom in now.

We are going to look at the private health care subsystem first.

The text says most personal health care is provided here.

Yes.

Overwhelmingly.

If you get sick this is usually where you go first.

The scope of the private subsystem is just massive.

It covers everything from health promotion and prevention.

Like getting a flu shot at your doctor's office.

Exactly.

To early detection like a mammogram.

All the way to cure, rehabilitation and custodial care.

And it happens everywhere.

Everywhere.

In clinics, physician offices, hospitals, skilled care facilities and increasingly in the patient's own home.

Home health is a huge growth area.

I found this section on the evolution of models really interesting.

It's a bit of a history lesson but it explains so much about why things look the way they do today.

It does.

It shows the trajectory of the profession.

If you go back in time we had the historic model.

It was very simple.

What did that look like?

You had a physician in a solo office.

Maybe they made home visits with a black bag.

You only went to the hospital if you had a very serious complication or honestly if you were dying.

The text calls that solo practice but that model is pretty much dying out isn't it?

It's fading fast.

It's just very very hard to survive financially as a solo doctor in today's complex regulatory and insurance environment.

So we have moved to the current reality which is dominated by highly skilled interprofessional teams.

The text outlines five basic models of care that nursing students really need to know.

Let's run through them so we can distinguish them.

Number one was solo practice which we said is fading.

What is number two?

Number two is the single specialty group.

This is where you have a group of physicians in the same specialty.

Let's say you know six orthopedic surgeons who join forces.

And why do they do that?

Money and time.

They pool their expenses.

They share an office.

They share income.

It's a way to reduce overhead but also to share the burden of being on call 247.

That makes a lot of sense.

Strengthen numbers.

What's number three?

Number three is the multi -specialty group.

This provides for interaction among different specialty areas.

So in one practice you might have an internal medicine doctor, a pediatrician, and an OBGYN all under one roof.

Which is great for the patient because you can get multiple needs met in one building theoretically.

Exactly.

It can improve coordination of care.

Then you have number four, the integrated health maintenance model.

That sounds a bit more corporate.

It is.

This is where you have prepaid multi -specialty physicians.

This is the precursor to and the current reality of what we call managed care.

Think of big systems like Kaiser Permanente where the insurance company and the providers are all part of the same entity.

Okay.

We'll definitely come back to managed care.

What's number five?

This one seems particularly relevant for our listeners who are studying community health.

Community health centers.

These are crucial.

They were developed through federal funds starting way back in the 1960s.

The key differentiator here is that they don't just treat illness.

They address the broader inputs into health.

What do you mean by inputs?

Things like education, housing, nutrition, transportation.

A community health center recognizes that you can't cure a patient's asthma if they're living in a mold So they look at the social determinants of health.

Precisely.

They serve the populations that the private for -profit model often leaves behind because it's not profitable.

You mentioned managed care a moment ago.

The text identifies this as a dominant paradigm in the private sector.

I feel like students hear this term constantly, but let's actually unpack what it means.

It's

in how the money flows.

We shifted from fee for service to capitated payments.

Okay.

Let's define those clearly for everyone.

What is fee for service?

Fee for service is exactly what it sounds like.

It's like going to a restaurant.

You order an appetizer, you pay for it.

You order a steak, you pay for it.

So in medicine?

The doctor performs a test.

They bill the insurance company for that test and they get paid.

They do a surgery, they bill for the surgery, they get paid.

Which creates an incentive to do more stuff.

Exactly.

The more you do, the more you make.

And this system is a huge reason why costs just went through the roof.

So managed care came along and introduced capitation.

Capitation.

That means per head, right?

From the Latin.

Right.

In a capitated model, the provider is paid a set amount, a flat fee per patient per month,

regardless of how much care that patient needs.

So if the patient is healthy and never comes in, the provider keeps the profit.

Yes.

And if the patient is very sick and needs a million dollars of care,

the provider or the health system eats that cost.

They take the risk.

So the incentive completely flips.

Now the incentive is to keep the patient healthy so they don't need expensive care.

Correct.

That's the theory.

It's designed to encourage efficiency and prevention.

But critics would say it also encourages withholding care or making it hard to see a specialist to save money.

This shift has also changed who provides the care.

It's not just doctors anymore, is it?

It's a huge change.

We are seeing more and more advanced nurse practitioners or AMPs and physician assistants, PAs, assuming primary practice roles.

And that's driven by cost.

It's driven by cost.

If you're being paid a flat fee, you want to provide care in the most cost effective way possible.

AMPs provide incredibly high quality care at a lower cost than, say, a specialized surgeon.

So that's why we see retail health clinics popping up in supermarkets and pharmacies.

Exactly.

That is managed care in action.

Accessible, convenient, lower cost points of entry into the system for basic needs.

The text also mentions patient -centered medical homes.

That sounds nice and cozy, but what is it technically?

It's a model that is relatively new and is strongly connected to health care reform.

The idea is a team approach.

You, the patient, have a medical home where a dedicated team coordinates all of your care, your specialists, your labs, your therapy, to ensure positive outcomes.

It's trying to fix the fragmentation.

That's the goal.

Fixing the problem of your cardiologist not knowing what your endocrinologist is doing.

The text notes that its long -term success is still unknown, but it's a major trend students absolutely should be aware of.

Before we leave the

text calls them non -official agencies.

These are your non -governmental, non -profit entities, and there's a really fascinating history lesson here that explains where they came from.

I love the history parts.

They provide so much context.

Well, the text explains that in early US history, we didn't really have these.

The early settlers and pioneers, they weren't used to organized charity.

They were rugged individualists.

You took care of your own.

It wasn't part of the culture.

Not at all.

It wasn't until the late 1800s that this changed.

The era of the robber barons.

The industrial revolution.

You had wealthy business people, Rockefeller, Carnegie, Mellon, who amassed these huge fortunes.

And with that came a sense of social responsibility or maybe social pressure.

And they started setting up foundations to address health and social problems.

This was the birth of the voluntary health sector in America.

And this is where we meet a major nursing icon, a hero of

Lillian Wald.

Every nursing student should know her name.

She established nursing practices in large cities like New York, specifically for the poor.

But she didn't just hand out medicine advantages.

What made her approach different?

What made it public health?

She looked at the whole picture.

She focused on working conditions in the factories,

living conditions in the tenements, language skills for immigrants.

She understood that health is social.

That work is really the public health nursing in this country.

It's amazing how relevant that is today.

Completely.

The text classifies these voluntary agencies into a few buckets.

I think it's helpful to list them so listeners can categorize them in their heads.

Sure.

First, you have agencies for specific diseases.

Think of the American Cancer Society or the American Diabetes Association.

Their whole mission is one disease.

Okay, that's straightforward.

Then you have agencies for specific organ or body structures, like the American Heart Association or the National Kidney Foundation.

Got it.

Third, you have agencies for special groups.

The March of Dimes, which originally focused on polio but now focuses on babies, or the National Council on Aging.

And finally, agencies for phases of health, like Planned Parenthood, which focuses on reproductive health.

And their role isn't just to fundraise and run commercials?

No, they are critical for innovation, prevention, promotion,

and crucially for filling gaps in the system.

The text gives a great example that I love.

The Chicken Soup Brigade.

I saw that.

It sounds like a made -up name, but it's real.

Oh, very real.

It's an organization that provides meals for clients with HIV AIDS who are too sick to cook for themselves.

That is a vital health service nutrition that a hospital isn't set up to provide, and the government might be too slow or underfunded to provide.

The voluntary sector steps in to fill that gap.

That's a perfect example.

Okay, so that's a deep dive into the private subsystem.

Now, let's cross the aisle.

Let's step into the public health subsystem.

This is where the government gets involved.

And this all starts with the U .S.

Constitution.

But the text points out something really interesting.

The Constitution doesn't actually mention the word health.

Not once.

It doesn't, which is fascinating.

But it does mandate that the federal government promote the general welfare.

The general welfare clause.

Exactly.

That simple phrase is the legal basis for all federal involvement in health care.

It's the loophole, essentially, that allows the government to regulate drugs,

fund hospitals, build the NIH, and fight epidemics.

So under that general welfare umbrella, let's look at the federal -level subsystem.

The big player here is HHS.

The Department of Health and Human Services.

And it is massive.

It's the second -largest federal department right behind the Department of Defense.

That really gives you a sense of the scale.

It does.

It shows you where the money goes.

It's led by the Secretary of HHS and, of course, the Surgeon General, who is sort of the nation's top doctor.

And there's a great nursing highlight here that the text mentions.

Yes.

Rear Admiral Sylvia Trent -Adams.

She is a nurse who served as the Acting Surgeon General in 2017.

It's a powerful reminder to students that there is no ceiling.

Nurses can and do reach the absolute highest levels of leadership in the federal government.

I love that.

Now, the text lists a bunch of key agencies under HHS.

We call this the alphabet soup of federal agencies.

Box 11 .1 breaks them down.

Let's hit the main ones quickly so everyone is clear on who does what.

Okay.

First, the CDC Centers for Disease Control and Prevention.

The Disease Detectives.

Exactly.

They handle prevention and epidemics.

When a new virus pops up, they're the ones on the ground.

Then you have CMS Centers for Medicare and Medicaid Services.

The money.

They hold the purse strings for those two massive insurance programs.

Their decisions affect every single hospital and clinic in the country.

Which makes them incredibly powerful.

Incredibly.

Then the FDA Food and Drug Administration.

They handle the safety of food, drugs, medical devices.

And the NIH, the National Institutes of Health.

That is the research arm.

And importantly for our listeners.

Within the NIH is the NINR, the National Institute for Nursing Research.

It's so important to know there's a federal body dedicated specifically to funding and promoting nursing science.

And there's also the IHS.

The Indian Health Service.

They have a direct responsibility to provide care for Native Americans and Alaska Natives based on treaties.

The scope of the federal system is pretty broad, isn't it?

It is very broad.

It targets the general population with things like hazard protection and collecting vital statistics, counting births and deaths.

But it also targets special populations like veterans, federal prisoners, and indigenous peoples.

And it works internationally with the WHO and the Red Cross on global health issues.

Okay, moving down a level.

The state level.

The expert insight here, and this is a quote from the text, is that states are the central authorities.

That is a key phrase to memorize for any exam.

States are the central authorities in the public health system.

Under the US federalist structure, states hold what's called the police power to regulate health and safety within their borders.

What does that mean in practice?

They're the ones who license you as a nurse.

They regulate the hospitals and nursing homes.

They usually have a state health department directed by a health commissioner who is often a physician.

But they aren't totally independent, are they?

They can't just do whatever they want.

No.

And this is where the politics get very, very messy.

States have the authority, but they often lack the money.

So they are highly dependent on federal resources, on federal funding.

And the text uses the ACA and Medicaid expansion as the prime example of this tension.

It's the perfect example.

The ACA offers states a huge pot of federal money to expand their Medicaid programs to cover more low -income adults.

It sounds like a great deal.

Well, the Supreme Court ruled that states could choose whether or not to take the money and expand.

And what was the result?

It was a patchwork.

As of the text publication, 31 states and DC chose to expand, but 19 states did not.

That single decision made at the state level has a massive impact on whether a low -income person in that state can see a doctor or not.

It's a life -or -death decision, really.

So the state sets the policy and accepts or rejects the funding.

But who actually does the work on the ground?

That brings us to the final level.

The local health department, or LHD,

this is where the rubber meets the road.

They are responsible for the direct delivery of public health services to the community.

What does that look like on a daily basis?

It varies a lot.

It can be a city department, a county department, or a regional one.

But generally, they provide four major categories of services.

OK, let's break those four down.

What's the first one?

First is community health.

This is the classic public health stuff.

Yeah.

Communicable disease control,

immunizations, maternal child health programs like WIC.

If you work as a public health nurse at the health department, this is likely what you are doing.

To second.

Environmental health.

This includes food hygiene inspecting restaurants, handling hazardous substances,

and pollution control.

They're the ones who show up after a chemical spill.

Third.

Personal health.

This is providing direct care to specific populations, like running clinics in schools, in prisons, or providing home health visits to home -bound seniors.

Mental health.

These services are often supported by local or regional funds, and they're a critical part of the public health safety net.

And the ACA impacted this local level too, right?

Yes.

The ACA recognized that if you want to fix health care, you have to fund the front lines.

It provided increased funds for community health centers, and specifically for nurse -managed clinics, empowering nurses to be a bigger part of the solution.

OK, whew.

We've covered the systems, the broad, private, and public structures.

Now I want to populate this world.

Let's talk about the people and places.

The health care providers.

It's a diverse ecosystem.

You have the provider organizations,

hospitals, clinics, home health agencies, hospice, and now these retail clinics you see in supermarkets.

But there's a major trend the text identifies.

Hospitals are changing.

How so?

They seem like permanent fixtures.

They are, but they're merging into massive health systems and sometimes closing, especially in rural areas.

But more importantly, there's a huge shift toward ambulatory care, which just means outpatient care.

Why is that happening?

Efficiency and money.

It is so much cheaper to treat people outside the four walls of a hospital.

So the goal is to keep them out if at all possible.

What does that mean for the nurse working inside the hospital?

It means the patients you do see are much, much sicker.

They have higher acuity, and their lengths of stay are shorter.

The hospital wants to stabilize them and discharge them as fast as possible to a skilled nursing facility or to home care.

It dramatically speeds up the pace of work.

This brings up a pretty heavy ethical question the text poses.

It asks straight out, is health care a right?

It is the fundamental ethical dilemma of the American system.

The text notes that the US is the only developed country without some form of universal coverage.

Even with the ACA, 28 million people remained uninsured in 2016.

That is a staggering number.

It is.

And as a provider, you are constantly facing this tension.

Who determines access?

If a patient can't pay, do they get the life -saving surgery?

The text doesn't solve this for you, but it warns you that you will face this dilemma your entire career.

Before we get to the specific professional roles, there is a box in the text box 11 .2 that distinguishes between primary care and primary prevention.

I feel like this is a classic exam trap.

It absolutely is.

Students mix these up all the time.

Let's clarify it.

Primary care refers to a level of the system.

It is the first point of contact, like your family physician or your nurse practitioner.

It is the setting where you go for common illnesses.

So it's a place or a type of service.

Exactly.

And primary prevention is an action or an intervention.

It's doing something to prevent disease before it even happens, like giving an immunization or teaching a nutrition class.

So to put it together, primary prevention can happen within a primary care setting.

Exactly.

You walk into a primary care office setting and you get a flu shot, primary prevention.

If you can remember that, you'll be fine.

Perfect.

Now let's look at the team.

The text calls this the alphabet soup of professionals, which is very accurate.

The list is long.

The RN, registered nurse, is the largest single group of health professionals.

But even within RN, there's a lot of variety.

You have diploma nurses, associate degree nurses, and BSN prepared nurses.

And the text notes that many nurses are now getting master's and doctoral degrees.

We mentioned AMPs earlier.

Advanced nurse practitioners.

The demand for them is just skyrocketing because of health reform and the need for cost -effective primary care providers.

What about the CNL?

That's a newer acronym for some people.

The CNL Clinical Nurse Leader.

This is a master's prepared role.

The text describes them as a manager of care at the point of care.

They are systems thinkers on a specific unit.

How is that different from a CNS clinical nurse specialist?

That's a great question.

A CNS clinical nurse specialist usually has a master's in a specific clinical specialty like oncology or cardiac care.

They are the expert on that condition.

A CNL is an expert in managing the unit's outcomes.

They oversee the coordination of care for a whole group of patients to make sure everything goes smoothly and quality metrics are met.

So one is a clinical expert.

The other is a systems expert.

That's a good way to think about it.

The text notes that CNS numbers are dropping a bit as the AMP role grows, but the CNL role is emerging to fill that systems level gap.

Okay.

We also have nurse midwives, CRNAs who are nurse anesthetists, and LPNSLVNs.

And then there's a term that the text uses, physician extenders.

Yes.

That is the text's term for physician assistants, EAs.

They work under the supervision of a physician to, as the name implies,

extend the physician's reach and see more patients.

And we can't forget the rest of the interdisciplinary team.

It's not just nurses and doctors.

Not even close.

You have dieticians, social workers, who are absolutely critical for discharge planning occupational and physical therapists, pharmacists, and respiratory therapists.

And one group that the text notes causes some controversy, UAP,

unlicensed assistive personnel.

Your CNAs, your tech support, your patient care aides.

The text says they're controversial because their training and scope can vary widely from state to state and facility to facility.

But frankly, they are critical for direct care.

You cannot run a hospital or a long -term care facility without them helping with the absolute basics of daily living.

The text also gives a nod to non -traditional providers.

Complementary and alternative medicine, or CAM.

This is your massage, herbal therapy, yoga, acupuncture, correnderose in some cultures.

Is this still considered fringe medicine?

Not anymore.

The text makes a point to say that the NIH, the National Institutes of Health, actually established the National Center for Complementary and Integrative Health.

That's federal recognition.

That's huge.

It means it's being studied seriously.

Patients are demanding these services, so nurses need to be aware of them and how they might interact with traditional Western medicine.

Okay, let's pivot.

We understand the system.

We understand the players.

Now we need to look at the critical issues in healthcare delivery.

These are the pain points.

And the first one is massive, quality care.

This is huge.

For a long time, we just sort of assumed care was good.

But in 1999, the Institute of Medicine released a landmark report called To Err is Human.

That's a famous title.

What did it find?

It was shocking.

It estimated that somewhere between 44 ,000 and 98 ,000 deaths occur each year in US hospitals due to preventable medical errors.

That's a stadium full of people dying from mistakes.

Exactly.

It completely shifted the entire conversation about safety.

It moved the focus from blaming individuals, Nurse Jones made a mistake, to fixing systems.

Why did the system allow this mistake to happen in the first place?

And who is leading the charge on fixing this at the federal level?

The main agency is AHRQ, the Agency for Healthcare Research and Quality.

They fund research on safety and best practices.

And they use something called CHPS surveys to report consumer experiences.

I've heard of CHPS.

That's the survey patients get in the mail after a hospital stay.

Yes.

Did the nurse explain things clearly?

Was the room quiet at night?

That data is collected and made public.

It's a way to hold hospitals accountable from the patient's perspective.

Connected to quality is accreditation.

This is how we prove that we're providing good, safe care.

Accreditation instills public confidence.

But more importantly, it is required for reimbursement.

If you aren't accredited, Medicare will not pay you.

And if Medicare doesn't pay you?

You close your doors.

It's that simple.

So accreditation is not optional.

Who are the main gatekeepers here?

The big one for hospitals and home care agencies is the Joint Commission.

If you work in a hospital, you know the panic when the Joint Commission is coming for a survey.

They check everything from medication safety to fire drills.

And for health plans and insurance.

That's the NCQA, the National Committee for Quality Assurance.

They're the ones who accredit health plans and MCOs.

And these are report card called HEADES.

HEADES, another acronym to remember.

Health Plan Effectiveness Data and Information Set.

It's a tool with a bunch of performance measures.

It asks questions like, what percentage of your diabetic patients have their blood sugar under control?

Or what percentage of your female patients over 50 got a mammogram?

And Medicare uses this data?

Medicare uses this data to grade the health plans and determine payments.

Good scores mean more money.

Okay, let's talk about managed care again.

This time is a critical issue.

We defined it earlier, but why is it listed as a problem here?

Because of the massive impact it has on everything.

The text reiterates that managed care affects what care is provided, where it's provided, when it's provided, and who provides it.

It is the primary mechanism of cost containment, but it creates this constant friction with patient choice and provider autonomy.

And then there's information technology, IT.

The digital revolution in healthcare.

The text mentions the ITEC Act and the ACA, which pushed very hard with financial incentives.

For the nationwide adoption of EHRs, electronic health records.

What's the verdict on EHRs?

Have they solved all our problems?

Not quite.

It's definitely mixed.

The pros are obvious, better data sharing, no more doctors, horrible handwriting, potential for improved safety with allergy alerts.

And the cons?

High cost to implement, clunky software that causes burnout,

different systems that don't talk to each other, and of course, huge privacy and liability concern.

And IT isn't just EHRs.

No, the text also points to telehealth, which is crucial for providing access to people in rural areas.

And then you have social media and health apps, which are new frontiers for tracking health and sharing information.

Speaking of privacy, that leads right into consumerism and patient rights.

Patients are smarter now.

They have Google.

And the text points to the baby boomers as a major driving force here.

They demand more care, they're more educated, and they are very critical of the system when it doesn't meet their needs.

They want to be partners in their care.

Exactly.

They want to be partners, not just passive subjects.

And they have rights.

What are the big ones?

IPA, the Health Insurance Portability and Accountability Act, protects their privacy.

But there's also the patient's Bill of Rights that exists in many facilities, guaranteeing things like confidentiality and the right to informed consent.

Another issue the text highlights is coordination and access.

The big problem here is fragmentation.

We have what the text calls handoffs.

When a patient moves from the ER to the ICU or from the hospital to home health, that is a high -risk zone.

Why is it so risky?

Information gets lost, orders get confused, medications are missed.

That is where a huge percentage of medical errors happen.

And you also have competition.

Hospitals compete for clients and resources, which can lead to a duplication of high -tech services in one rich suburb and a total desert of care in a poor rural area.

And finally, a really heavy one to end this section on,

disparities in healthcare delivery.

It is, and it is absolutely crucial for every nursing student to understand.

Disparities are observable differences in the presence of disease, health outcomes, or access to care among different groups.

And the statistics, the text quotes from the Kaiser Family Foundation are just stark.

Lay them out for us.

Blacks and Native Americans have significantly higher rates of asthma, diabetes, and cardiovascular disease than whites.

For HIV AIDS, blacks have 8 to 10 times higher rates of diagnosis than whites.

8 to 10 times?

That's not a small difference.

It's a chasm.

And infant mortality, which is a key indicator of a nation's health, is significantly higher for minorities.

And what are the factors driving this?

It's not just genetics.

No, the text is clear.

It's race, socioeconomic status, age, mental health status, geography, and sexual orientation.

The system, whether intentionally or not, does not treat everyone equally.

And the outcomes reflect that.

So with all these challenges, what is the future?

The chapter wraps up by looking forward.

It poses a lot of questions.

We face the unknowns.

Who gets access to care?

Who pays for it?

What services are actually provided?

And we face new and evolving threats.

The opioid crisis, gang violence, new viruses like Zika.

The challenges don't stop.

But there is a roadmap specifically for nurses.

The text highlights the big future of nursing report that came out from the IOM in 2011.

This is the manifesto for the modern nurse.

Every student should read it.

The text highlights four key messages for you, the student, to take away.

Let's hear them.

This is important.

One, nurses should practice to the full extent of their education and training.

Don't let outdated rules or bureaucratic barriers stop you from doing what you are trained and licensed to do.

So fight for your scope of practice.

Yes.

Two, achieve higher levels of education.

The text calls for seamless academic progression.

More nurses getting their BSNs and more getting their doctoral degrees to become researchers, educators, and leaders.

Three, be full partners with physicians and other professionals in redesigning health care.

Not subordinates partners.

You have a valuable perspective at the bedside that needs to be heard in the boardroom.

And the last one.

Four,

better data collection for workforce planning.

We need to know where our nurses are, what they do, and what we'll need in the future so we can plan effectively.

The goals are patient -centered care, stronger primary care, and more community -based care.

Exactly.

That is the mission.

That's the future we're trying to build.

So that is the system.

We have unpacked the machine.

We've looked at the blueprints, the wiring, the moving parts, and the places where it's breaking down.

It's a lot.

But if you take one thing away from this whole chapter, remember this.

Federal, state, and local legislation affects everything you do as a nurse.

And you cannot do it alone.

Interprofessional care is the only way this complex machine works.

And you, the student, you need to understand reimbursement and policy and advocacy to truly help your future clients navigate this maze.

Absolutely.

Your voice matters.

Thank you so much for joining us on this deep dive.

This has been the last -minute lecture team helping you decode the health care system.

Keep studying.

You've got this.

See you next time.