Discussion: Ambulatory Care

Discussion: Ambulatory Care ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Discussion: Ambulatory Care This assignment reinforces information in your textbook and concepts presented in this unit. Complete the questions and items below. It is recommended that you work through this assignment as you complete your reading assignment. Discussion: Ambulatory Care Questions What is ambulatory care? (Two or three sentences is an appropriate response.) Identify and briefly describe 5 ambulatory settings. Then compare and contrast in more detail 2 of your choosing. (Two paragraphs is an appropriate response.) Based on the trends in ambulatory care today, what will the models of the future will look like? (One paragraph is an appropriate response.) Justify your response. Cite at least one credible source in addition to support your justification. Cite your source using APA. Discussion: Ambulatory Care chapter_1.pdf chapter_4.pdf chapter_5.pdf chapter_12.pdf 4/9/2017 ECPI: Health Care USA: Understanding Its Organization and Delivery CHAPTER 1 Overview of Health Care: A Population Perspective This chapter provides a broad overview of U.S. health care industry, its policy makers, its values and priorities, and its responses to problems and changing conditions. A template for understanding the natural histories of diseases and the levels of medical intervention is illustrated and explained. Major in?uences in the advances and other changes to the health services system are described with pertinent references to the Patient Protection and Affordable Care Act (ACA). Issues of con?icts of interest and ethical dilemmas resulting from medicine’s technologic advances are also noted. Health care continuously captures the interest of the public, political leaders, and all forms of media. News of medical breakthroughs, health system de?ciencies, high costs and, most recently, federal health care reform through the Patient Protection and Affordable Care Act (ACA) attract high-pro?le attention. Consuming over 17% of the nation’s gross domestic product,1 exceeding $2.7 trillion in costs,2 and employing a workforce of over 16 million,3 it is understandable that health care occupies a central position in American popular and political discourse. In large measure, the development and passage of the ACA resulted from decades-long problems with rising costs, questionable quality, and lack of health care system access for large numbers of unor underinsured Americans. If the ACA is successful in accomplishing its intended goals by 2019, it will extend health insurance coverage to 32 million presently uninsured people; the remaining uninsured will be illegal immigrants, low-income individuals who do not enroll in Medicaid, and others who choose to pay a penalty rather than purchase coverage.4 Discussion: Ambulatory Care The current projected cost of ACA implementation is just under $1.1 trillion.5 Compared with seven other developed nations (the U.K., Germany, Sweden, Canada, France, Australia, and Japan), Americans’ health status lags sorely behind on important indicators. The United States ranks eighth behind all of these nations in life expectancy at birth, highest in infant mortality rate, and highest in the probability of people dying between the ages of 15 and 60 years.6 These are startling outcomes given that the United States continues a per capita annual health care expenditure that is triple that of Japan, which has the best health outcomes, and more than double that of several other of the aforementioned nations.2,7 Although the ACA will provide vastly increased access to health care for 30+ million Americans, there are strong reasons for policy makers’ focus on whether increased access can result in measurable improvements in Americans’ health status. “Health policy researchers are increasingly aware of the dangers of overstating the link between insurance and health.”8 As some suggest, ultimately improvements in population health will require the ACA’s success in merging the concepts of public health into the reformed system’s approach to personal medical care.4 With the ACA’s overarching emphasis on prevention and wellness and realigned ?nancial incentives to support these, there is even reason for optimism that “over time, prevention and wellness could become a dominant aspect of primary care.”4 For many, the fortunes and foibles of health care take on deeply serious meanings. There was a widespread sense of urgency among employers, insurers, consumer groups, and other policy makers about the seemingly unresolvable problems of inadequate access, rising costs, and questionable quality of care.Discussion: Ambulatory Care Passionate debates about the ACA in health care reform focused many Americans on the role health care plays in their lives and about the strengths and de?ciencies of the complex labyrinth of health care providers, facilities, programs, and services. Problems of Health Care Although philosophical and political differences historically fueled the debates about health care policies and reforms, consensus ?nally emerged that U.S. health care system is fraught with problems and dilemmas. Despite its decades-long series of impressive accomplishments, the health care system exhibits inexplicable contradictions in objectives; unwarranted variations in performance, effectiveness, and ef?ciency; and long-standing discord in its relationships with the public and with governments. The strategies for addressing the problems of cost, access, and quality over the 75 years since the passage of the Social Security Act re?ected the periodic changes in political philosophies. The government-sponsored programs of the 1960s were designed to improve access for older adults and low-income populations without considering the in?ationary effects on costs. These programs were followed by regulatory attempts to address ?rst the availability and price of health services, then the organization and distribution of health care, and then its quality. In the 1990s, the ineffective patchwork of government-sponsored https://ecpi.vitalsource.com/#/books/9781284055139/c?/6/24!/4/250/[email protected]:83.1 1/13 4/9/2017 ECPI: Health Care USA: Understanding Its Organization and Delivery health system reforms was superseded by the emergence of market-oriented changes, competition, and privately organized managed care organizations (MCOs). The failure of government-initiated reforms created a vacuum, which was ?lled quickly by the private sector. Discussion: Ambulatory Care There is a difference, however, between goals for health care reform of the government and those of the market. Although the proposed government programs try to maintain some balance among costs, quality, and access, the primary goal of the market is to contain costs and realize pro?ts. As a result, there remain serious concerns that market-driven reforms may not result in a health care system that equitably meets the needs of all Americans and may even drive up costs.9 As the recent querulous debate over health care reform illustrated, when the dominant interest groups—government, employers, insurers, the public, and major provider groups—do not agree on how to change the system to accomplish widely desired reforms, the American people would rather continue temporizing. They are “unwilling to risk the strengths of our existing health care system in a radical effort to remedy admittedly serious de?ciencies.”10 Understanding Health Care Health care policy usually re?ects public opinion. Finding acceptable solutions to the perplexing problems of health care depends on public understanding and acceptance of both the existing circumstances and the bene?ts and risks of proposed remedies. Many communication problems regarding health policy stem from the public’s inadequate understanding of health care and its delivery system. Early practitioners purposely fostered the mystique surrounding medical care as a means to set themselves apart from the patients they served. Endowing health care with a certain amount of mystery encouraged patients to maintain blind faith in the capability of their physicians even when the state of the science did not justify it.Discussion: Ambulatory Care When advances in the understanding of the causes, processes, and cures of speci?c diseases revealed that previous therapies and methods of patient management were based on erroneous premises, new information remained opaque to the American public. Although the world’s most advanced and pro?cient health care system provides a great deal of excellent care, the lack of public knowledge has allowed much care to be delivered that was less than bene?cial and some that was inherently dangerous. Now, however, the romantic naïveté with which health care and its practitioners were viewed has eroded signi?cantly. Rather than a con?dential contract between the provider and the consumer, the health care relationship now includes a voyeuristic collection of insurers, payers, managers, and quality assurers. Providers no longer have a monopoly on health care decisions and actions. Although the increasing scrutiny and accountability may be onerous and costly to physicians and other providers, it represents the concerns of those paying for health care—governments, insurers, employers, and patients—about the value received for their expenditures. That these questions have been raised re?ects the prevailing opinion that those who now chafe under the scrutiny are, at least indirectly, responsible for generating the excesses in the system while neglecting the problems of limited access to health care for many. Cynicism about the health care system grew with more information about the problems of costs, quality, and access becoming public. Discussion: Ambulatory Care People who viewed medical care as a necessity provided by physicians who adhere to scienti?c standards based on tested and proven therapies have been disillusioned to learn that major knowledge gaps contribute to highly variable use rates for therapeutic and diagnostic procedures that have produced no measurable differences in outcomes. Nevertheless, as the recent discussions about system-wide reforms demonstrated, enormously complex issues underlie the health industry’s problems. “The quest for greater ef?ciency in the delivery of health care services is eternal in a country that spends far more on health care than any other, consistently has growth in spending that outstrips that of income, is unable to provide insurance coverage to at least 17% of its population, and ranks poorly among industrialized countries in system-wide measures such as life expectancy and infant mortality.”11 Why Patients and Providers Behave the Way They Do The evolution of U.S. hospital system makes clear the long tradition of physicians and other health care providers behaving in an authoritarian manner toward patients. In the past, hospitalized patients, removed from their usual places in society, were expected to be compliant and grateful to be in the hands of professionals far more learned than themselves. More recently, however, recognizing the bene?ts of more proactive roles for patients and the improved outcomes that result, both health care providers and consumers are encouraging patient participation in health care decisions under the rubric of “shared decision making.”12 Indexes of Health and Disease The body of statistical data about health and disease has grown enormously since the late 1960s, when the government began analyzing the information obtained from Medicare and Medicaid claims, and computerized hospital and insurance data allowed the retrieval and exploration of clinical information ?les. Discussion: Ambulatory Care In addition, there have been continuing improvements in the collection, analysis, and reporting of vital statistics and communicable and malignant diseases by state and federal governments. Data collected over time and international comparisons reveal common trends among developed countries. Birth rates have fallen and life expectancies have lengthened so that older people make up an increasing proportion of total populations. The https://ecpi.vitalsource.com/#/books/9781284055139/c?/6/24!/4/250/[email protected]:83.1 2/13 4/9/2017 ECPI: Health Care USA: Understanding Its Organization and Delivery percentage of individuals who are disabled or dependent has grown as health care professions have improved their capacity to rescue otherwise moribund individuals. Infant mortality and maternal mortality, the international indicators of social and health care improvement, have continued to decline in the United States but have not reached the more commendable levels of countries with more demographically homogeneous populations. In the United States, the differences in infant mortality rates between inner-city neighborhoods and suburban communities may be greater than those between developed and undeveloped countries. The continuing inability of the health care system to address those discrepancies effectively re?ects the system’s ambiguous priorities. Natural Histories of Disease and the Levels of Prevention For many years, epidemiologists and health services planners have used a matrix for placing everything known about a particular disease or condition in the sequence of its origin and progression when untreated; this schema is called the natural history of disease. Many diseases, especially chronic diseases that may last for decades, have an irregular evolution and extend through a sequence of stages. Discussion: Ambulatory Care When the causes and stages of a particular disease or condition are de?ned in its natural history, they can be matched against the health care interventions intended to prevent the condition’s occurrence or to arrest its progress after its onset. Because these health care interventions are designed to prevent the condition from advancing to the next, and usually more serious, level in its natural history, the interventions are classi?ed as the “levels of prevention.” Figures 1-1, 1-2, and 1-3 illustrate the concept of the natural history of disease and levels of prevention. The ?rst level of prevention is the period during which the individual is at risk for the disease but is not yet affected. Called the “prepathogenesis period,” it identi?es the behavioral, genetic, environmental, and other factors that increase the individual’s likelihood of contracting the condition. Some risk factors, such as smoking, may be altered, whereas others, such as genetic factors, may not. When such risk factors combine to produce a disease, the disease usually is not manifest until certain pathologic changes occur. This stage is a period of clinically undetectable, presymptomatic disease. Medical science is working diligently to improve its ability to diagnose disease earlier in this stage. Because many conditions evolve in irregular and subtle processes, it is often dif?cult to determine the point at which an individual may be designated “diseased” or “not diseased.” Thus, each natural history has a “clinical horizon,” de?ned as the point at which medical science becomes able to detect the presence of a particular condition. Discussion: Ambulatory Care Because the pathologic changes may become ?xed and irreversible at each step in disease progression, preventing each succeeding step of the disease is therapeutically important. This concept emphasizes the preventive aspect of clinical interventions. FIGURE 1-1 Natural History of Any Disease in Humans. Source: Reprinted with permission from H. R. Leavell and E. G. Clark, Preventative Medicine for the Doctor in His Community: An Epidemiologic Approach, 3rd edition, p. 20, © 1965, The McGraw Hill Companies, Inc. https://ecpi.vitalsource.com/#/books/9781284055139/c?/6/24!/4/250/[email protected]:83.1 3/13 4/9/2017 ECPI: Health Care USA: Understanding Its Organization and Delivery FIGURE 1-2 Levels of Application of Preventative Measures. Source: Reprinted with permission from H. R. Leavell and E. G. Clark, Preventative Medicine for the Doctor in His Community: An Epidemiologic Approach, 3rd edition, p. 21, © 1965, The McGraw Hill Companies, Inc. https://ecpi.vitalsource.com/#/books/9781284055139/c?/6/24!/4/250/[email protected]:83.1 4/13 4/9/2017 ECPI: Health Care USA: Understanding Its Organization and Delivery FIGURE 1-3 Natural History of Cancer. Source: Reprinted with permission from H. R. Leavell and E. G. Clark, Preventative Medicine for the Doctor in His Community: An Epidemiologic Approach, 3rd edition, pp. 272–273, © 1965, The McGraw Hill Companies, Inc. Primary prevention, or the prevention of disease occurrence, refers to measures designed to promote health (e.g., health education to encourage good nutrition, exercise, and genetic counseling) and speci?c protections (e.g., immunization and the use of seat belts).Discussion: Ambulatory Care Secondary prevention involves early detection and prompt treatment to achieve an early cure, if possible, or to slow progression, prevent complications, and limit disability. Most preventive health care is currently focused on this level. Tertiary prevention consists of rehabilitation and maximizing remaining functional capacity when disease has occurred and left residual damage. This stage represents the most costly, labor-intensive aspect of medical care and depends heavily on effective teamwork by representatives of a number of health care disciplines. Figure 1-4 illustrates the natural history and levels of prevention for the aging process. Although aging is not a disease, it is a condition that is often accompanied by medical, mental, and functional problems that should be addressed by a range of health care services at each level of prevention. The natural history of diseases and the levels of prevention are presented to illustrate two very important aspects of U.S. health care system. First, it quickly becomes apparent in studying the natural history and levels of prevention for almost any of the common causes of disease and disability that the focus of health care historically has been directed at the curative and rehabilitative side of the disease continuum. The serious attention paid to refocusing the system on the health promotion/disease prevention side of those disease schemas re?ected in the National Prevention Strategy of the ACA13 came about only after the https://ecpi.vitalsource.com/#/books/9781284055139/c?/6/24!/4/250/[email protected]:83.1 5/13 4/9/2017 ECPI: Health Care USA: Understanding Its Organization and Delivery costs of diagnostic and remedial care became an unacceptable burden and the lack of adequate insurance coverage for over 49 million Americans became a public and political embarrassment. The second important aspect of the natural history concept is its value in planning community services. The illustration on aging provides a good example by suggesting health promotion and speci?c protection measures that could be applied to help maintain positive health status. FIGURE 1-4 Natural History of Aging. Source: Reprinted with permission from H. R. Leavell and E. G. Clark, Preventative Medicine for the Doctor in His Community: An Epidemiologic Approach, 3rd edition, pp. 272–273, © 1965, The McGraw Hill Companies, Inc. Major Stakeholders in U.S. Health Care Industry To understand the health care industry, it is important to recognize the number and variety of its stakeholders. Discussion: Ambulatory Care The sometimes shared and often con?icting concerns, interests, and in?uences of these constituent groups cause them to shift alliances periodically to oppose or champion speci?c reform proposals or other changes in the industry. The Public First and foremost among health care stakeholders are the individuals who consume the services. Although all are concerned with the issues of cost and quality, those who are uninsured or underinsured have an overriding uncertainty about access. It remains uncertain as to whether U.S. public will someday wish to treat health care like other inherent rights, such as education, but the passage of the ACA suggests that there is general agreement that some basic array of health care services should be available to all U.S. citizens. As the country waits to judge the success of the ACA in opening access to the previously uninsured, consumer organizations, such as the American Association of Retired Persons, and disease-speci?c groups, such as the American Cancer Society, the American Heart Association, and labor organizations, remain politically active on behalf of various consumer constituencies. Employers Employers constitute an increasingly in?uential group of stakeholders in health care because they not only pay for a high proportion of the costs but also take proactive roles in determining what those costs should be. Large private employers, coalitions of smaller private employers, and public employers wield signi?cant authority in insurance plan negotiations. In additio … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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Discussion: Ambulatory Care

Discussion: Ambulatory Care ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Discussion: Ambulatory Care This assignment reinforces information in your textbook and concepts presented in this unit. Complete the questions and items below. It is recommended that you work through this assignment as you complete your reading assignment. Discussion: Ambulatory Care Questions What is ambulatory care? (Two or three sentences is an appropriate response.) Identify and briefly describe 5 ambulatory settings. Then compare and contrast in more detail 2 of your choosing. (Two paragraphs is an appropriate response.) Based on the trends in ambulatory care today, what will the models of the future will look like? (One paragraph is an appropriate response.) Justify your response. Cite at least one credible source in addition to support your justification. Cite your source using APA. Discussion: Ambulatory Care chapter_1.pdf chapter_4.pdf chapter_5.pdf chapter_12.pdf 4/9/2017 ECPI: Health Care USA: Understanding Its Organization and Delivery CHAPTER 1 Overview of Health Care: A Population Perspective This chapter provides a broad overview of U.S. health care industry, its policy makers, its values and priorities, and its responses to problems and changing conditions. A template for understanding the natural histories of diseases and the levels of medical intervention is illustrated and explained. Major in?uences in the advances and other changes to the health services system are described with pertinent references to the Patient Protection and Affordable Care Act (ACA). Issues of con?icts of interest and ethical dilemmas resulting from medicine’s technologic advances are also noted. Health care continuously captures the interest of the public, political leaders, and all forms of media. News of medical breakthroughs, health system de?ciencies, high costs and, most recently, federal health care reform through the Patient Protection and Affordable Care Act (ACA) attract high-pro?le attention. Consuming over 17% of the nation’s gross domestic product,1 exceeding $2.7 trillion in costs,2 and employing a workforce of over 16 million,3 it is understandable that health care occupies a central position in American popular and political discourse. In large measure, the development and passage of the ACA resulted from decades-long problems with rising costs, questionable quality, and lack of health care system access for large numbers of unor underinsured Americans. If the ACA is successful in accomplishing its intended goals by 2019, it will extend health insurance coverage to 32 million presently uninsured people; the remaining uninsured will be illegal immigrants, low-income individuals who do not enroll in Medicaid, and others who choose to pay a penalty rather than purchase coverage.4 Discussion: Ambulatory Care The current projected cost of ACA implementation is just under $1.1 trillion.5 Compared with seven other developed nations (the U.K., Germany, Sweden, Canada, France, Australia, and Japan), Americans’ health status lags sorely behind on important indicators. The United States ranks eighth behind all of these nations in life expectancy at birth, highest in infant mortality rate, and highest in the probability of people dying between the ages of 15 and 60 years.6 These are startling outcomes given that the United States continues a per capita annual health care expenditure that is triple that of Japan, which has the best health outcomes, and more than double that of several other of the aforementioned nations.2,7 Although the ACA will provide vastly increased access to health care for 30+ million Americans, there are strong reasons for policy makers’ focus on whether increased access can result in measurable improvements in Americans’ health status. “Health policy researchers are increasingly aware of the dangers of overstating the link between insurance and health.”8 As some suggest, ultimately improvements in population health will require the ACA’s success in merging the concepts of public health into the reformed system’s approach to personal medical care.4 With the ACA’s overarching emphasis on prevention and wellness and realigned ?nancial incentives to support these, there is even reason for optimism that “over time, prevention and wellness could become a dominant aspect of primary care.”4 For many, the fortunes and foibles of health care take on deeply serious meanings. There was a widespread sense of urgency among employers, insurers, consumer groups, and other policy makers about the seemingly unresolvable problems of inadequate access, rising costs, and questionable quality of care.Discussion: Ambulatory Care Passionate debates about the ACA in health care reform focused many Americans on the role health care plays in their lives and about the strengths and de?ciencies of the complex labyrinth of health care providers, facilities, programs, and services. Problems of Health Care Although philosophical and political differences historically fueled the debates about health care policies and reforms, consensus ?nally emerged that U.S. health care system is fraught with problems and dilemmas. Despite its decades-long series of impressive accomplishments, the health care system exhibits inexplicable contradictions in objectives; unwarranted variations in performance, effectiveness, and ef?ciency; and long-standing discord in its relationships with the public and with governments. The strategies for addressing the problems of cost, access, and quality over the 75 years since the passage of the Social Security Act re?ected the periodic changes in political philosophies. The government-sponsored programs of the 1960s were designed to improve access for older adults and low-income populations without considering the in?ationary effects on costs. These programs were followed by regulatory attempts to address ?rst the availability and price of health services, then the organization and distribution of health care, and then its quality. In the 1990s, the ineffective patchwork of government-sponsored https://ecpi.vitalsource.com/#/books/9781284055139/c?/6/24!/4/250/[email protected]:83.1 1/13 4/9/2017 ECPI: Health Care USA: Understanding Its Organization and Delivery health system reforms was superseded by the emergence of market-oriented changes, competition, and privately organized managed care organizations (MCOs). The failure of government-initiated reforms created a vacuum, which was ?lled quickly by the private sector. Discussion: Ambulatory Care There is a difference, however, between goals for health care reform of the government and those of the market. Although the proposed government programs try to maintain some balance among costs, quality, and access, the primary goal of the market is to contain costs and realize pro?ts. As a result, there remain serious concerns that market-driven reforms may not result in a health care system that equitably meets the needs of all Americans and may even drive up costs.9 As the recent querulous debate over health care reform illustrated, when the dominant interest groups—government, employers, insurers, the public, and major provider groups—do not agree on how to change the system to accomplish widely desired reforms, the American people would rather continue temporizing. They are “unwilling to risk the strengths of our existing health care system in a radical effort to remedy admittedly serious de?ciencies.”10 Understanding Health Care Health care policy usually re?ects public opinion. Finding acceptable solutions to the perplexing problems of health care depends on public understanding and acceptance of both the existing circumstances and the bene?ts and risks of proposed remedies. Many communication problems regarding health policy stem from the public’s inadequate understanding of health care and its delivery system. Early practitioners purposely fostered the mystique surrounding medical care as a means to set themselves apart from the patients they served. Endowing health care with a certain amount of mystery encouraged patients to maintain blind faith in the capability of their physicians even when the state of the science did not justify it.Discussion: Ambulatory Care When advances in the understanding of the causes, processes, and cures of speci?c diseases revealed that previous therapies and methods of patient management were based on erroneous premises, new information remained opaque to the American public. Although the world’s most advanced and pro?cient health care system provides a great deal of excellent care, the lack of public knowledge has allowed much care to be delivered that was less than bene?cial and some that was inherently dangerous. Now, however, the romantic naïveté with which health care and its practitioners were viewed has eroded signi?cantly. Rather than a con?dential contract between the provider and the consumer, the health care relationship now includes a voyeuristic collection of insurers, payers, managers, and quality assurers. Providers no longer have a monopoly on health care decisions and actions. Although the increasing scrutiny and accountability may be onerous and costly to physicians and other providers, it represents the concerns of those paying for health care—governments, insurers, employers, and patients—about the value received for their expenditures. That these questions have been raised re?ects the prevailing opinion that those who now chafe under the scrutiny are, at least indirectly, responsible for generating the excesses in the system while neglecting the problems of limited access to health care for many. Cynicism about the health care system grew with more information about the problems of costs, quality, and access becoming public. Discussion: Ambulatory Care People who viewed medical care as a necessity provided by physicians who adhere to scienti?c standards based on tested and proven therapies have been disillusioned to learn that major knowledge gaps contribute to highly variable use rates for therapeutic and diagnostic procedures that have produced no measurable differences in outcomes. Nevertheless, as the recent discussions about system-wide reforms demonstrated, enormously complex issues underlie the health industry’s problems. “The quest for greater ef?ciency in the delivery of health care services is eternal in a country that spends far more on health care than any other, consistently has growth in spending that outstrips that of income, is unable to provide insurance coverage to at least 17% of its population, and ranks poorly among industrialized countries in system-wide measures such as life expectancy and infant mortality.”11 Why Patients and Providers Behave the Way They Do The evolution of U.S. hospital system makes clear the long tradition of physicians and other health care providers behaving in an authoritarian manner toward patients. In the past, hospitalized patients, removed from their usual places in society, were expected to be compliant and grateful to be in the hands of professionals far more learned than themselves. More recently, however, recognizing the bene?ts of more proactive roles for patients and the improved outcomes that result, both health care providers and consumers are encouraging patient participation in health care decisions under the rubric of “shared decision making.”12 Indexes of Health and Disease The body of statistical data about health and disease has grown enormously since the late 1960s, when the government began analyzing the information obtained from Medicare and Medicaid claims, and computerized hospital and insurance data allowed the retrieval and exploration of clinical information ?les. Discussion: Ambulatory Care In addition, there have been continuing improvements in the collection, analysis, and reporting of vital statistics and communicable and malignant diseases by state and federal governments. Data collected over time and international comparisons reveal common trends among developed countries. Birth rates have fallen and life expectancies have lengthened so that older people make up an increasing proportion of total populations. The https://ecpi.vitalsource.com/#/books/9781284055139/c?/6/24!/4/250/[email protected]:83.1 2/13 4/9/2017 ECPI: Health Care USA: Understanding Its Organization and Delivery percentage of individuals who are disabled or dependent has grown as health care professions have improved their capacity to rescue otherwise moribund individuals. Infant mortality and maternal mortality, the international indicators of social and health care improvement, have continued to decline in the United States but have not reached the more commendable levels of countries with more demographically homogeneous populations. In the United States, the differences in infant mortality rates between inner-city neighborhoods and suburban communities may be greater than those between developed and undeveloped countries. The continuing inability of the health care system to address those discrepancies effectively re?ects the system’s ambiguous priorities. Natural Histories of Disease and the Levels of Prevention For many years, epidemiologists and health services planners have used a matrix for placing everything known about a particular disease or condition in the sequence of its origin and progression when untreated; this schema is called the natural history of disease. Many diseases, especially chronic diseases that may last for decades, have an irregular evolution and extend through a sequence of stages. Discussion: Ambulatory Care When the causes and stages of a particular disease or condition are de?ned in its natural history, they can be matched against the health care interventions intended to prevent the condition’s occurrence or to arrest its progress after its onset. Because these health care interventions are designed to prevent the condition from advancing to the next, and usually more serious, level in its natural history, the interventions are classi?ed as the “levels of prevention.” Figures 1-1, 1-2, and 1-3 illustrate the concept of the natural history of disease and levels of prevention. The ?rst level of prevention is the period during which the individual is at risk for the disease but is not yet affected. Called the “prepathogenesis period,” it identi?es the behavioral, genetic, environmental, and other factors that increase the individual’s likelihood of contracting the condition. Some risk factors, such as smoking, may be altered, whereas others, such as genetic factors, may not. When such risk factors combine to produce a disease, the disease usually is not manifest until certain pathologic changes occur. This stage is a period of clinically undetectable, presymptomatic disease. Medical science is working diligently to improve its ability to diagnose disease earlier in this stage. Because many conditions evolve in irregular and subtle processes, it is often dif?cult to determine the point at which an individual may be designated “diseased” or “not diseased.” Thus, each natural history has a “clinical horizon,” de?ned as the point at which medical science becomes able to detect the presence of a particular condition. Discussion: Ambulatory Care Because the pathologic changes may become ?xed and irreversible at each step in disease progression, preventing each succeeding step of the disease is therapeutically important. This concept emphasizes the preventive aspect of clinical interventions. FIGURE 1-1 Natural History of Any Disease in Humans. Source: Reprinted with permission from H. R. Leavell and E. G. Clark, Preventative Medicine for the Doctor in His Community: An Epidemiologic Approach, 3rd edition, p. 20, © 1965, The McGraw Hill Companies, Inc. https://ecpi.vitalsource.com/#/books/9781284055139/c?/6/24!/4/250/[email protected]:83.1 3/13 4/9/2017 ECPI: Health Care USA: Understanding Its Organization and Delivery FIGURE 1-2 Levels of Application of Preventative Measures. Source: Reprinted with permission from H. R. Leavell and E. G. Clark, Preventative Medicine for the Doctor in His Community: An Epidemiologic Approach, 3rd edition, p. 21, © 1965, The McGraw Hill Companies, Inc. https://ecpi.vitalsource.com/#/books/9781284055139/c?/6/24!/4/250/[email protected]:83.1 4/13 4/9/2017 ECPI: Health Care USA: Understanding Its Organization and Delivery FIGURE 1-3 Natural History of Cancer. Source: Reprinted with permission from H. R. Leavell and E. G. Clark, Preventative Medicine for the Doctor in His Community: An Epidemiologic Approach, 3rd edition, pp. 272–273, © 1965, The McGraw Hill Companies, Inc. Primary prevention, or the prevention of disease occurrence, refers to measures designed to promote health (e.g., health education to encourage good nutrition, exercise, and genetic counseling) and speci?c protections (e.g., immunization and the use of seat belts).Discussion: Ambulatory Care Secondary prevention involves early detection and prompt treatment to achieve an early cure, if possible, or to slow progression, prevent complications, and limit disability. Most preventive health care is currently focused on this level. Tertiary prevention consists of rehabilitation and maximizing remaining functional capacity when disease has occurred and left residual damage. This stage represents the most costly, labor-intensive aspect of medical care and depends heavily on effective teamwork by representatives of a number of health care disciplines. Figure 1-4 illustrates the natural history and levels of prevention for the aging process. Although aging is not a disease, it is a condition that is often accompanied by medical, mental, and functional problems that should be addressed by a range of health care services at each level of prevention. The natural history of diseases and the levels of prevention are presented to illustrate two very important aspects of U.S. health care system. First, it quickly becomes apparent in studying the natural history and levels of prevention for almost any of the common causes of disease and disability that the focus of health care historically has been directed at the curative and rehabilitative side of the disease continuum. The serious attention paid to refocusing the system on the health promotion/disease prevention side of those disease schemas re?ected in the National Prevention Strategy of the ACA13 came about only after the https://ecpi.vitalsource.com/#/books/9781284055139/c?/6/24!/4/250/[email protected]:83.1 5/13 4/9/2017 ECPI: Health Care USA: Understanding Its Organization and Delivery costs of diagnostic and remedial care became an unacceptable burden and the lack of adequate insurance coverage for over 49 million Americans became a public and political embarrassment. The second important aspect of the natural history concept is its value in planning community services. The illustration on aging provides a good example by suggesting health promotion and speci?c protection measures that could be applied to help maintain positive health status. FIGURE 1-4 Natural History of Aging. Source: Reprinted with permission from H. R. Leavell and E. G. Clark, Preventative Medicine for the Doctor in His Community: An Epidemiologic Approach, 3rd edition, pp. 272–273, © 1965, The McGraw Hill Companies, Inc. Major Stakeholders in U.S. Health Care Industry To understand the health care industry, it is important to recognize the number and variety of its stakeholders. Discussion: Ambulatory Care The sometimes shared and often con?icting concerns, interests, and in?uences of these constituent groups cause them to shift alliances periodically to oppose or champion speci?c reform proposals or other changes in the industry. The Public First and foremost among health care stakeholders are the individuals who consume the services. Although all are concerned with the issues of cost and quality, those who are uninsured or underinsured have an overriding uncertainty about access. It remains uncertain as to whether U.S. public will someday wish to treat health care like other inherent rights, such as education, but the passage of the ACA suggests that there is general agreement that some basic array of health care services should be available to all U.S. citizens. As the country waits to judge the success of the ACA in opening access to the previously uninsured, consumer organizations, such as the American Association of Retired Persons, and disease-speci?c groups, such as the American Cancer Society, the American Heart Association, and labor organizations, remain politically active on behalf of various consumer constituencies. Employers Employers constitute an increasingly in?uential group of stakeholders in health care because they not only pay for a high proportion of the costs but also take proactive roles in determining what those costs should be. Large private employers, coalitions of smaller private employers, and public employers wield signi?cant authority in insurance plan negotiations. In additio … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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