Health Care System Evolution, Organizational Analysis and Continuum of Care

The objective of this work is to examine the evolution of the health care system and how health care delivery systems have influenced the current health care system in regards to Medicare/Medicaid. This work will conduct an organizational analysis for the Centers for Disease Control and Prevention including the stakeholders impacted by this component and how they are affected. Finally, this work will examine the continuum of care for Diabetes care program in the United States including the services provided and how these fit in the continuum of care. This work will examine how the equity contributes or fails to contribute to the overall management of healthcare resources and will examine the future trends of health care and discuss how these services will be impacted or the need to change to meet these future trends.

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The work entitled: “Evolution of Health Care, from 19th Century Till Today” states that Medicaid was created in 1965 as was Medicare. In 1983 changes were made and prospective payment for hospital admissions are stated to have been added. In 1992 a fee schedule for physicians was implemented and in 1993 there was a failed proposal for universal insurance coverage. In 1996 the health Insurance Portability of Insurance for job to job transitions was developed. In 1997 the Balanced Budget Act was enacted which expanded choices in Medicare. Finally, in 2003, Medicare and Medicaid reimbursement of drug costs were expanded. (European Observatory on Health Care Systems in Transition, WHO nd)

The work entitled: “Significance of Medicare and Medicaid Programs for the Practice of Medicine” states: “…1965, the Medicare and Medicaid Programs have enormous influence over the practice of medicine. The evolution of medical care, its’ financing, and the expectations of the American population for high-quality care and rational use of public funds have linked, irreversibly, CMS to clinical medicine. CMS finances health care for more Americans than any other single entity; the agency has responsibility to its beneficiaries to ensure that they receive quality, effective, and efficient health care.” (Health Care Financing Review, 2005) it is noted that CMS answers to not only beneficiaries but also to investors and taxpayers as well as addressing “the concerns of an array of political constituents, including Congress, presidential administrations, and groups representing the health care industry” (Health Care Financing Review, 2005)


In order that CMS effectively balance what are “competing interests” in its pursuit of “evolving policy goals” stated is that CMS “…has had no choice but to become engaged in the practice of medicine and the delivery of health care services.” (Health Care Financing Review, 2005) Clinical medicine is stated to have become “intertwined with CMS” in four areas:

1) the end-stage renal disease (ESRD) program;

2) the quality improvement organizations and the effectiveness initiative;

3) Financing of graduate medical education, and 4) State Medicaid activities. (Health Care Financing Review, 2005)

The work entitled: “The Health Care Delivery System: A Blueprint for Reform:” (2008) relates that six goals that have been identified for reform of the health care system include the following goals:

Safety – Avoiding injury and harm from care that is meant to aid patients;

Effectiveness – Assuring that “evidence-based” care is actually delivered by avoiding overuse of medically unproven care and underuse of medically sound care;

Patient-centeredness – Involving patients thoroughly in their care decision-making process, thereby respecting their culture, social circumstances, and needs;

Timeliness – Avoiding unwanted delays in treatment

Efficiency – Seeking to reduce waste — low-value-added processes and products — in all its forms, including supplies, equipment, capital, and space;

Equity – Closing racial, ethnic, gender, and socioeconomic gaps in care and outcomes. (Center for American Progress and the Institute on Medicine as a Profession, 2008)

Policy recommendations are stated to include:

Investing in federal scholarship and loan repayment programs – including the National Health Service Corps and the nursing scholarship and loan repayment programs — to ease the burden of educational expenses and encourage newly trained providers to practice in underserved areas or in primary care;

Creating a federal, long-term investment in comparative effectiveness research that will guide clinical practice and payment systems, increasing effective and efficient health care delivery; and Providing federal funds to support the acquisition of federally certified electronic health records, their maintenance, and the technical assistance needed to implement and use them effectively. This could include providing matching grants to safety net providers. (Center for American Progress and the Institute on Medicine as a Profession, 2008)


In a February 25, 2008, United States Government Accountability Office report it is related that the Centers for Disease Control & Prevention (CDC)’s new structure is of the nature that the agency’s organization consists of:

1) the CDC Office of the Director;

2) Coordinating centers; and 3) National centers.” (USGAO, 2008)

The USGAO states that the coordinating centers are inclusive of:

1) the Coordinating Office for Global Health;

2) the Coordinating Office for Terrorism Preparedness and Emergency Response;

3) the Coordinating Center for Environmental Health and Injury Prevention;

4) the Coordinating Center for Health Information and Service

5) the Coordinating Center for Health Promotion; and 6) the Coordinating Center for Infectious Diseases. (USGAO, 2008)

The coordinating centers are stated to be “intended to allow CDC’s scientists to collaborate and innovate across organizational boundaries, improve efficiency, and improve the internal services that support and develop CDC staff.” (USGAO, 2008) Four of these coordinating centers are stated to be that which oversee “…the activities at multiple national centers.” (USGAO, 2008)

Additionally the CDC is stated to have added “two new national centers, the National Center for Public Health Informatics and the National Center for Health Marketing.” (USGAO, 2008) the CDC employs in excess of 8,500 individual in the U.S. with approximately 65% of these living in the Atlanta, Georgia area and only 20% of employees located at CDC’s primary headquarters. The CDC has seven National Centers include:

The National Center on Birth Defects and Developmental Disabilities;

The National Center for Chronic Disease Prevention and Health Promotion;

The National Center for Environmental Health;

The National Center for Health Statistics;

The National Center for HIV, STD, and TB Prevention;

The National Center for Infectious Diseases; and the National Center for Injury Prevention and Control works to prevent death and disability from injuries that are not work-related, including both acts of violence and unintentional causes. (Thomson Gale, 2006)


The work of Homer, et al. (2004) entitled: “The CDC’s Diabetes Systems Modeling Project: Developing a New Tool for Chronic Disease Prevention and Control” relates the facts as follows: “Diabetes mellitus is a complex metabolic disorder marked by abnormally high blood glucose levels. If left untreated, the complications of diabetes can be disabling and ultimately fatal. Diabetes affects at least 18 million people in the U.S., a number that has been growing more rapidly than the general population since 1990. The rapid growth has occurred among those who have the non-insulin dependent Type 2 variety of the disease (formerly known as adult onset diabetes), as opposed to among the one million or so who have insulin-dependent Type 1 diabetes (which almost always strikes in childhood). Total costs of diabetes in the U.S. In 2002 were estimated to be $132 billion, with $92 billion of that in direct medical expenditures and the other $40 billion in indirect costs due to disability and premature mortality.” (Worcestershire Diabetes: a New Model of care Stakeholder event, 2007)

The CDC reports that it decided to “employ a system dynamics modeling as a tool for enhancing both learning and action.” (Worcestershire Diabetes: a New model of care Stakeholder event, 2007) the CDC reports having sought to create a structure with the following components:

1) Generic enough to be adaptable for other chronic diseases;

2) Realistic enough to reproduce national-level historical data on the prevalence of diabetes, prediabetes, and obesity;

3) Comprehensible enough to test practical policies without disaggregating the population into demographic categories of age, sex, race/ethnicity, or other individual attributes;

4) Broad enough to encompass a spectrum of policy measures that are being considered; and 5) Grounded enough in empirical experience that it does not require speculation beyond what the project participants themselves could agree upon or what credible evidence could support.(Worcestershire Diabetes: a New model of care Stakeholder event, 2007)

However, the CDC did not address the continuum of care for Diabetes. Common components in the diabetes continuum of care programs at various institutions include those as follows:

1) Diabetes care will ensure the patient is at the center of care and empower them to self-manage their condition;

2) Services will be responsive and flexible to meet the needs of individual patient;

3) Diabetic care should mainly be delivered in primary care/community settings;

4) Consultant led care should be easily and quickly accessible for patients with the most complex needs;

5) Diabetic specialist nurses will provide ‘intermediate level care’ in the community to support primary care professionals and patients’ with more complex needs;

6) Care pathways will be developed to support this model of care; and 7) Care Pathways will pay particular attention to age transitions. (Worcestershire Diabetes: a New model of care Stakeholder event, 2007)

The continuum of care for the diabetic patient is shown in the following illustration labeled Figure 1.

Diabetes: Continuum of Care

Source: Worcestershire Diabetes: a New model of care Stakeholder event (2007)

The continuum of care for diabetes begins at the moment that the individual is found to have diabetes and continues across the individual’s health care providers and across the varying stages of progression of the disease and the age progression of the individual with Diabetes. This continuum of care should be addressed by health care providers, Medicare/Medicaid, as well as the Centers for Disease Control and Prevention.

Changes in the workforce in developing the diabetes continuum of care is stated to have included the following: (1) Increase in number of dieticians; (2) Increase in number of diabetic specialist nurses; (3) Increase in podiatrists; (4) Education for primary care team; (5) Move DSN to primary care to take straight referrals; (6) Insulin for life training with continuous CPD support; (7) Increase capacity in general practice; (8) Psychologist input; (9) DSN provides education/advice for practices; (10) Increase confidence of G.Ps and Practice nurses to deliver care; (11) Out of hours service accessibility to advice post 6 p.m. (for patients and clinicians); and (12) DSN for elderly. (Worcestershire Diabetes: a New model of care Stakeholder event, 2007)

Clinical accommodations were stated to include: (1) Care pathways; (2) Identification of patient on admission to acute to pharmacist, DSN; (3) Continuity of care throughout the service where possible patient sees the same clinician; (4) Need shared templates, guidelines, protocols; (5) Retinal screening; and (6) Eye screening for housebound. (Worcestershire Diabetes: a New model of care Stakeholder event, 2007)

Communication accommodations supporting diabetes continuum of care included: (1) Countywide register accessible to all clinicians; (2) Increase family/school liaison; (3) Developed links between services; (4) Diabetic link nurses on all wards; (5) Shared templates/paperwork; (6) Use of available technology email referrals/advice etc.; (7) Information that flows freely to all parts of the service; and (8) Good data. (Worcestershire Diabetes: a New model of care Stakeholder event, 2007)

Public health and education accommodations to support diabetes continuum of care included: (1) Better transport; (2) Healthy diet; (3) Playing fields; (4) Educating parents, children on healthy lifestyles; and (5) Tie diabetes to other strategies to tackle obesity. (Worcestershire Diabetes: a New model of care Stakeholder event, 2007)

Patient education accommodations for supporting diabetes continuum of care is stated to include: (1) Structured patient education for type 2; (3) Structured patient education for type 1; and (3) Cluster-based training for newly diagnosed diabetics. The action along with the purpose taken in this diabetes continuum of care initiative are listed in the following table labeled Figure 2.

Diabetes Continuum of Care Actions/Purposes



Diabetes Network core group to meet

To agree terms of reference, structure and function of the network

Agree communication strategy.

Make final agreement on model of care following feedback

Decide how to deliver recommendations from the stakeholder event

Begin detailed action plan for circulation

Set up the Diabetes Structured Education Self-Care Group

To address the recommendations and requirements of NICE guidance, both technology appraisals and clinical guidelines, in relation to structured patient education, patient information and self-monitoring in accordance with the Worcestershire Model of Care for Diabetes. The group will be chaired by Sian Finn, Self-Care Programmes Manager for the PCT.

Complete the Diabetes Commissioning toolkit data collection

To benchmark our services. To provide baseline data to evaluate changes against. To ensure action plans can be prioritized appropriately based on health needs analysis.

To identify financial implications

Communicate outputs from Stakeholder event widely and gain feedback especially with patients groups.

To ensure all those with vested interest have a chance to contribute to the future of diabetes care in Worcestershire.

Identify and cost workforce options for delivering the model of care

To ensure robust workforce plans can be produced to support model of care

To allow open decision making process

Worcestershire Diabetes: a New model of care Stakeholder event (2007)

The ‘elements of care’ stated in the Diabetes continuum of care program are listed in the following table labelled Figure 3.

Diabetes Continuum of Care Elements





Prevention type 2

Heart disease/stroke##


Self-management information packs (1 group’s idea that these should be provided for all patients)

Structured Patient education


Diagnosis type 2 adult

Initial management type 2

Continuing care type 1

Continuing care type 2

Regular surveillance adults

Erectile dysfunction

Foot issues (surveillance)


Treatment change e.g. insulin

Institutional care (moving to 3 as clinically appropriate)

Elderly/housebound (moving to 3 as clinically appropriate)

Diagnosis type 1 adult (3 groups)

Initial management type 1 adult (2)

Psychological support (2)

Eye problems (1)

Initial management children and young people (moving to 4 as clinically appropriate)

Foot issues

Severe hypos (moving to 4 as clinically appropriate)

Diagnosis type 1 adult (1 group)

Initial management type 1 adult (2)

Psychological support (2)

Eye problems (1)

Diagnosis type 1 children and young people

Regular surveillance children and young people

Pregnancy – women with diabetes

Pregnancy – gestational


Non-diabetes admission

Diagnosis type 1 adult (1 group)

Initial management type 1 adult (1)

Eye problems (2 groups

Source: Worcestershire Diabetes: a New model of care Stakeholder event (2007)

The work of O’Reilly (2005) entitled: “Managing the Care of Patients with Diabetes in the Home Care Setting” published in the journal of Diabetes Spectrum states that patients “are released from hospitals and rehabilitation centers earlier in the continuum of care than ever before. Individuals with diabetes, either as a primary diagnosis or a comorbid condition, are no exception to this trend. This, combined with an end to the fee-for-service payment structure, has challenged home care clinicians to find effective ways of transitioning these patients from an acute episode of illness to a return to the community. Recognizing the impact of diabetes as an independent risk factor is key to achieving favorable health outcomes.” (O’Reilly, 2005)

The work of Paul Straley (2007) entitled: “Diabetes: Adherence to Preventative Care” states of diabetes that in the U.S. The risk for developing Type 1 diabetes is higher than almost all other chronic illnesses of childhood” However, diabetes is manageable “if the individual is committed to monitoring blood glucose levels and practicing lifestyle modifications.” (Straley, 2008) Straley’s report addresses diabetes care among adolescents in the United States and relates that being diagnosed with diabetes is the trigger of a plethora of stressor for individuals who are in their teenage years. Identified as the best nursing practice for promotion of successful diabetes care in adolescent Type 1 diabetes is stated to be achievable through management of “…psychosocial risks and adhering to preventive care.” (2008) Nursing strategies are identified as including:

1) Therapeutic communication;

2) Providing education; and 3) Promoting self-efficacy. (Straley, 2007)

This report highlights the role of the nurse and the nursing strategy in diabetes care and particularly in regards to the continuum of care of diabetes. It is stated that education is “an essential part of the third nursing strategy, promoting self-efficacy, and is supported by a collaborative multidisciplinary team.” (Straley, 2007) Nurses assist patients with autonomy reinforcement and initiates choices and collaboration in establishment of a diabetes self-care plan. Straley reports that ‘The Nurse Case Managed Integrated Care Model’ was introduced by the American Diabetes Association in 1997 with the purpose of providing “a continuum of care through a variety of multidisciplinary teams to educate families and provide self-efficacy in managed care of adolescents’ diabetes.” (2007) Straley notes the work of Caravalho & Saylor (2000) who stated that “Increased self-efficacy is an integral part of an empowerment education program.” (2007) Also reported was that self-efficacy “…was associated with better metabolic control.” (Straley, 2007) Indentified as ‘Barriers to Successful Nursing Interventions’ by Straley are the following:

The patient has a lack of financial resources or insufficient insurance;

Nurses are burdened with limited time and resources to build a positive therapeutic relationship;

Because of high medical costs there is a lack of follow-up and increased non-compliance;

Nurses are unable to provide consistency of care and develop intra-personal relationships that are indicative to building a sense of trust

The lack of follow up can make it difficult for the nurse to assess and evaluate knowledge deficits as it relates to adolescents’ diabetes and complications related to their illness. T

The limited ability to assess individual’s specific needs can lead to slowed response to providing community resources and can lead to further secondary complications. (Straley, 2007)


The Centers for Disease Control and Prevention have failed to properly address the Continuum of Care for Diabetes however, the professional nursing staff is in a unique position to enable the education and self-care of diabetes patients. Continuum of care programs through the U.S. And throughout the world, while differing in scope, have common components that serve to enable Diabetes patients in a Continuum of Care supported by education and autonomy in self-care of their diabetes.


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4. Acute consultant led

3. Intermediate care DSN led

DSN led

2. G.P / Practice nurse


1. Supported self – care