Page 245 - Encyclopedia of Nursing Research

212 n HeAlTH pOlIcy AND HeAlTH SerVIce DelIVery

are used to attain the policy goals. policy public entities that create laws and regula-
can be described as public, institutional, or tions impacting how health care systems
H organizational. public policy is formulated, should operate, be reimbursed, and mea-
adopted, and implemented by the authorities sure quality and safety of care. professional
in a political system often in the form of laws organizations set standards related to the
and regulations. Institutional policy governs education, practice, and work conditions for
workplaces and guides programs and pro- nurses.
cedures. professional organizations, such as Health service delivery can broadly be
the American Nurses Association, adopts viewed as a pyramid of four broad services
policies that are often n the form of position with population-based public health ser-
statements. vices at the base. Building from the base to
The World Health Organization (WHO, the pyramid’s peak are primary health care,
2003) defines health as “a state of complete secondary health care, and tertiary care ser-
physical, mental and social well-being and vices. population-based public health ser-
not merely the absence of disease or infir- vices include health promotion and disease
mity.” Health service delivery encompasses prevention activities at the community level,
activities that focus on health promotion and primary health services involve clinical pre-
prevention of disease, treatment, and reha- ventive services and care for common medi-
bilitation of individuals or populations in cal conditions, secondary health care services
a variety of settings. WHO (2007) identifies have a focus on specialized care and include
health services delivery as one of the build- support services for people with chronic
ing blocks of a national health system. Other or long-term health problems, and tertiary
building blocks include human resources, services are provided in facilities. The use
information, medical products, technol- of the pyramid to represent health services
ogy, and financing. Inputs such as human implies that each level serves a different por-
resources and finances combine to the deliv- tion of the total population. Since the passage
ery of health services. The higher the degree of Medicare and Medicaid in 1966, the U.S.
of health service delivery integrated, the health care delivery system has focused on
greater the continuity of care and the more services at the secondary and tertiary level.
efficient the organization of care is in attend- Health care delivery has occurred in silos,
ing to patient needs. Because efficiency gains with each silo providing different levels of
have an upper limit, many would argue that service.
there may be a trade-off with effectiveness public policy, specifically the 2010
that leads to vertical programs. patient protection and Affordable care Act,
The WHO definition of health services will change the U.S. health service deliv-
delivery focuses on a national perspective. In ery by shifting reimbursement from fee for
thinking of health services delivery at a more services at the top of the pyramid to a more
local level, Donabedian’s (1966) structure– coordinated health service delivery model
process–outcome framework and system’s with threads of health promotion and dis-
theory can be used to examine the impact ease prevention woven through all levels of
that health policies have on the health ser- delivery. The goal is to eliminate the silos
vices delivery. In systems theory, elements and to have an integration of health delivery
inside and outside the system are open and services. For example, a national voluntary
interrelated. They interact, adapt, and are pilot program for bundled payments will
constrained and in need of feedback. Health be developed by 2013. Under this program,
service delivery is embedded within a health services during one episode of care (for yet
care system. The health care system interacts to be identified diagnoses) will be reim-
with a variety of outside elements, such as bursed in one payment. The Act defines an