Healthcare Delivery Models and Organizational Structures
Key Points
- Health systems differ by financing model, governance, and service organization.
- Common model categories include Beveridge, Bismarck, National Health Insurance, and Out-of-Pocket structures.
- U.S. delivery includes for-profit, not-for-profit, and government institutions across public and private sectors.
- Integrated delivery systems improve continuity by linking services and information across care settings.
Pathophysiology
This concept describes macro-level health system design rather than disease physiology. System structure influences access, coordination, affordability, and quality outcomes.
Fragmentation across financing and delivery structures can produce uneven access and duplicated services. Integrated structures reduce these risks through unified networks and shared data.
Classification
- Financing models: Beveridge, Bismarck, National Health Insurance, Out-of-Pocket.
- Ownership structures: For-profit, not-for-profit, state/local government.
- Institution types: Public institutions, private institutions, and federally run service systems.
- Delivery design: Stand-alone sites versus integrated delivery systems (IDS).
Nursing Assessment
NCLEX Focus
Link patient barriers and care delays to system-level factors such as insurance, network structure, and referral pathways.
- Assess insurance/coverage context and likely affordability barriers.
- Assess which system type the patient is navigating (public, private, IDS, federal).
- Assess referral pathway complexity and risk of service fragmentation.
- Assess continuity threats during cross-organization transitions.
- Assess equity implications for underserved populations.
Nursing Interventions
- Guide patients through system navigation and referral processes.
- Coordinate with case management for network, coverage, and access barriers.
- Use integrated records and structured handoff to reduce duplication.
- Escalate system barriers affecting timely care delivery.
- Support patient-centered planning that fits real coverage and resource constraints.
System-Blind Planning
A clinically correct plan can still fail if delivery-model constraints and access barriers are not addressed.
Pharmacology
Medication access is strongly affected by coverage model and formulary structure; nurses should anticipate affordability and access barriers when planning treatment.
Clinical Judgment Application
Clinical Scenario
A patient receives specialty recommendations but misses follow-up due to network confusion and cost concerns.
Recognize Cues: Care plan failure is linked to system navigation and affordability barriers. Analyze Cues: Structural factors, not only patient motivation, are driving nonadherence. Prioritize Hypotheses: Priority is redesigning plan to match delivery-model realities. Generate Solutions: Engage care coordination, verify network options, and simplify referral path. Take Action: Implement revised system-aligned follow-up plan. Evaluate Outcomes: Attendance and continuity improve.
Related Concepts
- levels-of-care-primary-secondary-and-tertiary-framework - Operational movement through system tiers.
- patient-care-coordination-interdisciplinary-referrals-and-case-management - Team workflow for structural complexity.
- communication-barriers-emotional-intelligence-and-bias-awareness - Communication factors that amplify system barriers.
Self-Check
- How do financing models influence patient access to care?
- Why do integrated delivery systems often improve continuity?
- Which nursing actions best reduce harm from organizational fragmentation?