The activities and interests of the health care delivery system and the governmental public health agencies clearly overlap in certain areas, but there is relatively little collaboration between them. 1.1.1. Solanki G, Schauffler HH, Miller LS. Cooper-Patrick L, Gallo JJ, Powe NR, Steinwachs DM, Eaton WW, Ford DE. Although the terrorist incidents in the fall of 2001 did not directly test the ability of hospitals to respond to a medical crisis, they drew particular attention to hospitals' limited surge capacitythe ability to absorb a large influx of severely injured patientsin their emergency departments and specialty units. Using delivery system innovations to advance health care reform continues to be of widespread interest. As with other types of health services, insurance is a strong predictor of access to and use of dental services, and minorities and low-income populations are much less likely to have dental insurance or to receive dental care. Use of the word "delivery" is deprecated by critics who . Quality health care can be defined in many ways but there is growing acknowledgement that quality health services should be: Effective - providing evidence-based healthcare services to those who need them; Safe - avoiding harm to people for whom the care is intended; and In many cases, funds were no longer available for population-based essential public health services or had to be diverted to the more visibly urgent need of keeping clinics and hospitals open (CDC, 1997). The effects of oral diseases are cumulative and influence aspects of life as fundamental as the foods people can eat, their ability to communicate effectively, and their social acceptability. In a study analyzing more than 5 million patient discharges from 799 hospitals in 11 states, Needleman and colleagues (2001) consistently found that higher RN staffing levels were associated with a 3 to 12 percent reduction in indicatorsincluding lower rates of urinary tract infections, pneumonia, shock, and upper gastrointestinal bleeding and shorter lengths of staythat reflect better inpatient care. The lower quality of care also compounds the adverse health effects of other disadvantages faced by minorities, including lower incomes and education, less healthy living environments, and a greater likelihood of being uninsured. More than a third of poor children (ages 2 to 9) have one or more primary teeth with untreated decay, compared with 17.3 percent of nonpoor children (DHHS, 2000b). As a result of decreasing demand for hospital services and a changing financial environment, hospitals in many parts of the country reduced the number of patient beds, eliminated certain services, or even closed (McManus, 2001). The IOM Committee on the Changing Market, Managed Care and the Future Viability of Safety Net Providers defined safety-net providers as [t]hose providers that organize and deliver a significant level of health care and other health-related services to uninsured, Medicaid, and other vulnerable patients (IOM, 2000a: 21). Although cardiovascular disease is the leading cause of death and diabetes is one of the most significant chronic diseases affecting Medicare beneficiaries, physicians cannot screen for lipids disorders or diabetes unless the patient agrees to pay out-of-pocket for the tests. An employer may choose from several different ways to put money into a health benefits account for each employee and offer the employee a menu of coverage options, with different funding levels and employee financial responsibility for each. . These factors, in turn, improve the likelihood of disease screening and early detection, the management of chronic illness, and the effective treatment of acute conditions, IOM notes in a recent report (IOM, 2002a: 6). Of the 22.9 million children eligible for the EPSDT program in 1996, only 37 percent received a medical screen through the EPSDT program. Adequate population health cannot be achieved without making comprehensive and affordable health care available to every person residing in the United States. 2002. It is also associated with having a regular source of care and with greater and more appropriate use of health services. First, as noted earlier, AHCs are an important part of the safety-net system in most urban areas. Focuses on quality of care, not volume of services provided Aligns incentives across all parts of our system, with patients at the center, delivering high-value care and keeping costs reasonable Invests in new technologies and innovations to advance quality of care For example, time pressures on physicians hamper their ability to accurately assess presenting symptoms, especially when cultural or language barriers are present. Research consistently finds that persons without insurance are less likely to have any physician visits within a year, have fewer visits annually, and are less likely to have a regular source of care (15 percent of uninsured children do not have a regular provider, whereas just 5 percent of children with Medicaid do not have a regular provider), and uninsured adults are more than three times as likely to lack a regular source of care. In the aggregate, these per capita expenditures account for 13.2 percent of the U.S. gross domestic product, about $1.3 trillion (Levit et al., 2002). 2001. Poor oral care can also contribute to oral cancer, and untreated tooth decay can lead to tooth abscess, tooth loss, andin the worst casesserious destruction of the jawbone (Meadows, 1999). SOURCES: Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, Wittchen HU, Kendler KS. And more importantly, what can we learn from one another? 1996. These circumstances force public health departments to provide personal health care services instead of using their resources and population-level approaches to guide and support community efforts to change the conditions for health. States are experiencing serious pressures from growth in Medicaid spending, which increased by about 13 percent from 2001 to 2002, following a 10.6 percent increase in 2001 (NASBO, 2002a). The Surgeon General's report on mental illness (DHHS, 1999) estimates that more than one in five adults are affected by mental disorders in any given year (see Box 56) and 5.4 percent of all adults have a serious mental illness. Available in most communities. This would not be a problem if health care systems used currently available information technologies, including electronic medical records and internal disease surveillance systems. Additionally, disabling chronic conditions affect all age groups, but about two-thirds are found in individuals over age 65. 1999. Physical Health Untreated ear infections, for example, can have permanent consequences of hearing loss or deafness. Many hospitals participate in broad community-based efforts to achieve some of the conditions necessary for health, for instance, collaborating with community development corporations to contribute financial, human, and technical resources (U.S. Department of Housing and Urban Development, 2002). Other types of public health surveillance activities, such as registries for cancer cases and for childhood immunizations, also depend on reporting from the health care system. . Crossing the Quality Chasm (IOM, 2001b: 28) found that the prevailing model of health care delivery is complicated, comprising layers of processes and handoffs that patients and families find bewildering and clinicians view as wasteful . 2002. An estimated 100 million Americans have one or more chronic conditions, and that number is estimated to reach 134 million by 2020 (Pew Environmental Health Commission, 2001). Unfortunately, the Medicare program was not designed with a focus on prevention, and the process for adding preventive services to the Medicare benefit package is complex and difficult. Four Components of Health Care: H.R. As of fiscal year 1996, only nine states reported meeting or exceeding the federally established goal. Other changes in the health care delivery system also raise concerns about the infectious disease surveillance system. . 4 Components of the United State health care delivery system. The resources of the health care delivery system are not balanced well enough to provide patient-centered care, to address the complex health care demands of an aging population, to absorb normal spikes in demand for urgent care, and to manage a large-scale emergency such as that posed by a terrorist attack. Counseling to address serious health riskstobacco use, physical inactivity, risky drinking, poor nutritionis least likely to be covered by an employer-sponsored health plan. The fourth component is health care. Even when insured, limitations on coverage may still impede people's access to care. Medicare's pilot project IdeaTelInformatics for Diabetes Education and Telemedicineoffers web-based home systems to rural and inner-city diabetics to support home monitoring, customized information, and secure links to providers and to the patients' own medical records (www.dmi.columbia.edu/ideatel/info.html). Three levels of Health Care Primary Secondary Tertiary Primary Care Goal: To decrease the risk to a client (individual or community) of disease or dysfunction. The result of this interplay is that many governmental public health agencies have found themselves in a strained relationship with managed care organizations: on the one hand, encouraging their active partnership in an intersectoral public health system and, on the other, competing with them for revenues (Lumpkin et al., 1998). Lasker RD, 1998. Patients regularly spent significant portions of their admission on gurneys in a hallway. Identify a defined population (community) and develop links to that community Assess health status and need, and adjust the volume and types of services provided to respond to the health needs of (more). The Population Health Care Delivery Model. When risk factors, such as high blood pressure, can be identified and treated, the chances of developing conditions such as heart disease can be reduced. Many health care settings lack basic computer systems to provide clinical information or support clinical decision making. Substantial increases in health insurance premiums are a clear indication of these economic stresses. Health Research and Educational Trust. Disease surveillance and reporting provide a classic exemplar of essential collaboration between the health care system and the governmental public health agencies. In this system, health care is provided and financed by the government through tax payments, just like the police force or the public library. The U.S healthcare system is large and varied. In the United States, more than 18 million people who use alcohol and nearly 5 million who use illicit drugs need substance abuse treatment (SAMHSA, 2001). Hospitals are also employers, and in the case of two Lawndale, Illinois, hospitals, collaboration with the local development corporation and other neighborhood organizations in 1999 made affordable local housing available to employees, helping to facilitate community development (University of Illinois, 1999). Access to care: how much difference does Medicaid make? The Chronic Care Model [3,4,5] is a well-established organizational framework for chronic care management and practice improvement. Lazarus R, Kleinman K, Dashevsky I, Adams C, Kludt P, DeMaria A Jr, Platt R. 2002. Integrate cross-cultural education into the training of all current and future health care professionals. Rabinowitz J, Bromet EJ, Lavelle J, Hornak KJ, Rosen B. For these reasons, oral health must recognized as an important component of assuring individual and population health. However, when fewer diagnostic tests are performed for self-limiting illnesses like diarrhea, there may be delays in recognizing a disease outbreak. The limited and unstable nature of insurance for treatment of mental illness has several implications for governmental public health agencies because the severely mentally ill are likely to end up receiving care in publicly funded safety-net programs (Rabinowitz et al., 2001). 2. in the nursing interventions classification, a nursing intervention defined as monitoring and management of the patient during pregnancy to prevent complications of pregnancy and promote a healthy outcome for both mother and infant. (Eds.). Disease reporting is not complete, however. Reports of sentinel events have proved useful for the monitoring of many diseases, but such reports may be serendipitous and generated because of close clustering, unusual morbidity and mortality, novel clinical features, or the chance availability of medical expertise. This chapter addresses the issues of access, managing chronic disease, neglected health care services (i.e., clinical preventive services, oral, and mental health care and substance abuse services), and the capacity of the health care delivery system to better serve the population in terms of cultural competence, quality, the workforce, financing, information technology, and emergency preparedness. The health care delivery system is the policy, organizations, and regulations that promote positive patient health with direct, and indirect strategies. As discussed in Unequal Treatment (IOM, 2002b), the factors that may produce disparities in health care include the role of bias, discrimination, and stereotyping at the individual (provider and patient), institution, and health system levels.