Nursing: A Concept-Based Approach to Learning, 2nd Edition

Module 47 Health Policy The Concept of Health Policy Definitions Health policy Refers to actions and decisions by government bodies or professional organizations that influence the actions and decisions of organizations and individuals within the healthcare system Focuses on how organizations function within U.S. socioeconomic and political environment Nurses in unique position Roles as caregivers, communicators, teachers, advocates, counselors, change agents, leaders, managers, case managers, research consumers Help put health policy issues in context Shape policy planning American Nurses Association (ANA) promoting agenda in healthcare reform Favor basic health care for all citizens that focuses on primary care, prevention, and chronic disease management See CONCEPTS RELATED TO HEALTH POLICY, p. 2621 Developing health policies Process is problem-solving framework similar to nursing process Factors that affect development of policy Costbenefit ratios Client care issues Equity of access See Figure 471 WHY IS HEALTH POLICY RELEVANT TO NURSES p. 2620 Three phases Formulation Similar to assessment and planning Data collected Data used to define problems, identify desired outcomes Implementation Communication of adopted policies Putting policies into action Evaluation Additional data collected and analyzed Determine degree to which policy change achieved success See Table 471 APPLYING THE POLICY DEVELOPMENT PROCESS, p. 3 Enacted by governmental entity Through specific agency Changes made in incremental fashion Federal, state, local levels U.S. Department of Health and Human Services (DHHS) and U.S. Occupational Safety and Health Administration (OSHA) State departments of health and human services Local departments of health or social services Health Care and Education Reconciliation Act of 2010 Exemplar 47.1 Regulatory Agencies Overview Function ( help healthcare providers and agencies operate safely, legally, honestly, effectively Agencies typically enforce laws, rules that must be followed at organizational level Individual healthcare professionals regulated by licensure boards Federal agencies Department of Health and Human Services (DHHS) Principal agency for the protection of health of all Americans Provision of essential human services for those least able to care for themselves 300 divisions and programs Include National Institutes of Health (NIH), Centers for Medicare Medicaid Services (CMS) Administration for Children and Families, Administration on Aging Food and Drug Administration (FDA), Centers for Disease Control and Prevention (CDC), Agency for Healthcare Research and Quality (AHRQ) Occupational Safety and Health Administration (OSHA) Works to ensure health and safety of Americans in workplace Most employees in nation under OSHA jurisdiction Provide assistance to employers to reduce or eliminate workplace hazards Information and training materials Protect workers on the job Comply with standards that apply to establishment Ensure students have and use personal protective equipment (PPE) Issues standards for wide variety of workplace hazards State and local agencies State divisions of health and health services Every state has own division or department of health and human services Oversee regulation of County health departments Healthcare settings Child care centers Clinical laboratories Portable x-ray suppliers Oversee planning and construction of medial facilities Office of Emergency Medical Services (OEMS) Environmental health regulations Local health departments Oversee variety of health policies and regulations Disease monitoring and surveillance Child care center sanitation and food safety Injury prevention campaigns Special supplemental nutrition program for Women, Infants, and Children (WIC) Case Study A ( Emma Jones is a 29-year-old woman who works for a small manufacturing firm, p. 2624 Exemplar 47.2 Accrediting Bodies Overview Accreditation Peer review process for measuring quality of organizations Preparation requires examining own performance Standards of accrediting agency provide structure Management strategies and self-review The Joint Commission Independent, nonprofit organization Sets standards for and accredits healthcare organizations Mission to continuously improve safety and quality of care Through provision of healthcare accreditation and related services Three functional areas addressed by the Joint Commission (JC) Infection control Patients rights Patient treatment Focuses on organizations ability to provide safe effective care for clients Actual provision of safe, effective care Nursing Education Program Accreditation Commission on Collegiate Nursing Education (CCNE) National League for Nursing Accrediting Commission (NLNAC) Exemplar 47.3 Professional Organizations Overview Promote development of profession of nursing American Nurses Association (ANA) Only full-service professional organization representing nations RNs Advances nursing Fostering high standards of nursing practice Promoting the rights of nurses in workplace Projecting positive and realistic view of nursing Lobbying Congress and regulatory agencies on healthcare issues affecting nurses and public National Student Nurses Association (NSNA) Nonprofit organization for students enrolled in associates baccalaureate, diploma, and generic graduate nursing programs Fosters professional development of nursing students Provides access to the Virginia Henderson International Nursing Library Specialty practice organizations Specialty areas ( advocacy, education, and connection among practitioners Academy of Medical-Surgical Nurses Association of Pediatric Oncology Nurses ANA has list on Web site Sigma Theta Tau International Membership by invitation Baccalaureate and graduate nursing students Excellence in scholarship Nurse leaders exhibiting exceptional achievements in nursing National League for Nursing (NLN) Committed to delivering improved, enhanced, and expanded services Champions pursuit of high-quality nursing education Promoting excellence in nursing education to build strong, diverse nursing workforce American Association of Colleges of Nursing (AACN) National voice for U.S. baccalaureate and higher degree nursing education programs Educational, research, and governmental advocacy Data collection Publications Establish quality standards Assist with implementation Case Study B ( Damien Johnson, RN, BSN, graduated from university 10 years ago, p. 2626 Exemplar 47.4 Types of Reimbursement Overview Individuals and private insurers paid for health care in the U.S. until 1965 when the federal government started Medicare Affordable Care Act will greatly increase number of insured United States only industrialized country without national policy Payment sources Federal programs (public insurance) CMS (formerly Health Care Financing Administration HCFA) ( Medicare, Medicaid, State Childrens Health Insurance Program (SCHIP) Medicare ( aged 65 years or older, disabled, end-stage renal disease (ESRD) Four parts A ( premium-free hospital insurance B ( voluntary, premium, partial payment for physician visits, outpatient services Deductible and 20 copay C ( Medicare Advantage ( allows enrollment in private insurance D ( drug plans Medicaid Lower income individuals and families State-administered program Supplemental Security Income (SSI) Designed to help older, blind, disabled Cash for basic needs State Child Health Insurance Programs (SCHIP) Provides health insurance coverage to low-income children younger than 19 years of age Each state determines design of program Private and health insurance programs May be through employer, professional organization Most require individual to pay a monthly premium Coinsurance percentage Copayments fixed amount at time of service Blanket medical service in exchange for predetermined monthly payment Types of private health insurance Health maintenance organization (HMO) Member selects primary care provider ( gatekeeper Great range of services for lowest cost Restrictive ( limited choice of providers Preferred provider organization (PPO) No primary care provider (PCP) Larger network of providers Less restrictive Greater copayments Point of service (POS) Hybrid In or out of network May have higher copayment, coinsurance, deductibles Consumer-driven healthcare plan (CDHP) Health Savings Account (HSA) or Health Reimbursement Account (HRA) Greater payment toward healthcare expenses Lower premiums HSA, HRA to save money to pay expenses Private health insurance Coverage by plan through employer or union or Purchased by individual from private health insurance company Employment-based coverage may extend to spouse, dependents, domestic partner Self-employment based ( expensive Medigap policy Designed to supplement Medicare Helps pay some of costs that Medicare does not cover Personal payments Paid by client and not covered by any type of insurance Healthcare policies affect individuals, families on number of levels Almost daily basis Determine what drugs approved Services offered Types of providers who may provide services Review The Concept of Health Policy Relate Link the Concepts Refer Go to Nursing Student Resources Reflect Case Study 2015 by Education, Inc. 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