Unit 6- Community

tool: database

To find assistance in planning, implementing, and evaluation community health interventions and programs that address their focus on chronic disease

case management

a patient professional partnership that can be used to arrange a continuum of care for rural patients with the case manager blending formal and informal resources; allows patients to participate in their plan of care; outcomes are often remarkably different with case management is used

community advocates

key stakeholders

areas of action: strengthening community action

"tried and true" public health approach in which nurses listen and respond to the needs of the community. community members need to be involved in order to attain better health

Health professional shortage area

A physician or a nurse practitioner may provide services to residents who live in surrounding counties

Director

APN who is committed to nursing center model;Current knowledge of the target community, the ability and willingness to work with many community organizations and groups, and a background in organizational planning, administration and fiscal management; Responsible for oversight of contracts and grans, annual reports and development of the advisory board or board of directors; Hiring staff

researcher

Accesses and applies evidence based practices for programmatic and individual interventions with clients and communities

patient advocate

Acts as advocate, provides info and supports benefit changes that assist member, family, primary care provider and capitated systems

broker

Acts as an agent for provider services that are needed by clients to stay within coverage according to budget and cot limits of health care plan

Healthy Communities: A Rural Action Guide (North Carolina Smart Growth, 2004

Addressed features of rural communities and complements CDC's healthy community initiative and both promote establishing professional- community partnerships. Translating national objectives into achievable community health goals requires integration of the following components to ensure that services will be acceptable and appropriate for rural clients

coordinator

Arranges, regulates, and coordinates need health care services for clients at all necessary points of services

Utilization management

Attempts to promote optimal use of services to redirect care and monitor the appropriate use of provider care/ treatment services for both acute and community/ ambulatory services

care maps

Became the second generation of critical pathways of care

education and research

Clinical assignments through the nursing center model enable students of all levels to work with skilled clinicians and develop positive community collaborative and build their skills to become professionals; ___ provides the opportunity to gain answers to questions and share the findings with colleagues and public

Multilevel interventions

Community and the center work together for comprehensive community health, a multilevel approach is needed

tools: Community health and assessment group evaluation

Community leaders can use this tool to see what local policy, system, and environmental strategies are currently in place in their communities and identify areas where health strategies are needed.

steps to determine which area to target

Conduct a needs assessment and set health priorities; Find out what social and environmental factors may affect health as well as what are options; Think about acceptability and feasibility

disease management

Constitutes systematic activities to coordinate health care interventions and communications for populations with conditions in which client self care forts are significant

multisectoral cooperation

Coordinated action by all parts of a community, from local government officials to grassroots community members

mentor

Counsels and guides the development of the practice of new case managers

Rural

Defined in terms of the geographic location and population density, or it may be described in terms of the distance from (e.g., 20 miles) or the time (e.g., 30 minutes) needed to commute to an urban center.

are not as distinct

Differences between rural and urban _____ as they once were

systems allocator

Distributes limited health care resources according to a plan or rationale

educator

Educates clients, family, and providers about case management process, delivery system, community health resources, and benefit coverage so that informed decisions can be make by all parties

CDC's Healthy Communities program

Emphasizes policy, systems, and environmental changes that focus on chronic diseases and that encourage people to be more physically active, eat a healthy diet, and not use tobacco; "tools for community action"- can be used in developing healthy communities

quality improvement

Evidence based application exemplifies what nurses can do to measure outcomes, strive to improve those outcomes given particular standards, and make meaningful contributions to the publics health

wellness centers

Focus on health promotion, disease prevention, and management programs;Provide outreach and public awareness services, health education, immunizations, family assessment and screening services, home visiting, and social support;Complement existing primary care services- the staff maintains strong relationships with local health care providers in community health centers, clinics, private practices, long term care facilities, and other organizations;d. Financial support comes from public health departments and other service contracts, foundations grants, fee for services, voluntary contributions and shared resources; run by a nurse

health promotion

Focus on providing community members with a positive sense of health that strengthens their physical, mental, and emotional capacities

Rural Healthy People 2010: A Companion Document to Healthy People 2010

Focused on the particular concerns relative to vulnerable populations in rural environments

Red Cross Rural Nursing Service (1912)

Formal rural nursing originated with ______

standardization monitor

Formulates and monitors specific, time sequenced critical path and care map plans as well as disease management protocols that guide the type and timing of care to comply with predicted treatment outcome for the specific client and conditions

advocate clients interests

Frequent monitoring to assess alignment with goals and changing nature of client needs

Case management plans

Have evolved through various terms and methods; Standards of client care, standards of nursing practice, and clinical guidelines using evidence based practices for case management serve as core foundations of case management plans

policy development and health advocacy

Health advocacy is an essential nursing role in nurse managed health centers; Nurses involved focus on health disparities and access to care for all and promote the nursing center model as a system of public health and primary care services that reduces health disparities and improves ongoing access to health care; Roles of advocate can be as divers as working with a community group to reduce the exposure of vulnerable children to lead based paint in older homes to testifying in the house of representatives

primary health care

Health care that is typically not inside a hospital; refers to meeting the basic health needs of a community by providing readily accessible health services

nursing center

Health promotion place; Give patients direct access to professional nursing services; diagnose and tx human responses to health problems and promote health; Free standing or affiliated with universities

diagnosis

Identification of problem/ opportunity

feasibility study

Identifies the strengths, limitations, and capacity of an organization and the community to support the establishment and continuation of a nursing center; Requires interviews, surveys, and data collection from key informants, focus groups, and community forums

healthy place

Include access to health care services that include both treatment and prevention for all community members, the community will be safe, and there would be adequate roads, schools, playgrounds and other services to meet the needs of the people in the community and that the environment would be healthy and safe

areas of action: developing an individuals personal skills

Includes teaching people the skills that they need in order to be healthy, such as regular and competent hand washing, choosing the right foods, engaging in regular age- appropriate exercise, and learning to avoid risk factors and increase ones protective factors; increases the options available to people so they have more control over health and their environments

population management

Includes wellness and health promotion, illness prevention, acute and subacute care, rehabilitation, end of life care, and care coordination

CDC's Healthy Communities Initiative

Individuals and groups at the local level collaborated with state health departments, the CDC, and other organizations to implement programs that promote and support good health in their community. Useful tool for state and local officials and health care planners to use to tailor healthy people objectives to fit a communities specific needs.

community participation

Individuals within communities become involved with health promotion. Well informed and motivated community members participate in planning, implementing, and evaluation health programs

care management

Is a health care delivery process that helps achieve better health outcomes by anticipating and linking clients with the services they need more quickly

community practice

Locality development is a process-oriented model that emphasizes consensus, cooperation, and building group identity and a sense of community;Social planning stresses rational-empirical problem solving, usually by outside professional experts; social action aims to increase the problem solving ability of the community with concrete actions that attempt to correct the imbalance of power and make sure everyone has equal access

Problems faced by rural communities for generations

Maldistribution of health professionals, Poverty, Limited access to services, Ignorance and Social isolation

national and regional organizations

Membership will enable people to organize around one or more critical health threats and strategize about what interventions work; Lessons learned can be shared; Nursing can join and contribute their skills to advance the future of nursing; They choose based on interest, clinical and academic preparation and employment

Population Characteristics: Rural

More whites, Higher proportion of younger (under 18 years of age) and older residents (over 65 years of age), more likely to be married, more likely to be widowed (most female), more likely to be poorer (quality of life isn't poor, but amount of money per family is low), fewer years of formal education, at risk for being underinsured or uninsured

negotiator

Negotiates the plan of care, services, and payment arrangement with providers; uses effective collaboration and team strategies

bottom up approach

Partnership approach;Uses broad based community problem solving that includes health professionals, local officials, service providers, and other community members, including those at risk for health problems; Community participation is evident in all stages of community health planning and practice

emerging health systems

Primary heath care is now in forefront of prevention, early intervention, and community wide education when disasters occur; Communities must be prepared to meet the everyday needs of people as well as the unexpected; Participation in disaster and emergency response plans are essential

Informal social support systems

Prior to Red cross, care of the sick in small communities was provided by ______

top down approach

Professionals and experts tell the citizens what to do rather than involve and ask them

special care centers

Provide services and specialized health knowledge and skills to a particular group; Focus on the needs of people with diabetes or HIV/AIDS, adolescent mothers, the frail elderly, and support services for people with mental disorders; focus on type of health care challenge

liaison

Provides a formal communicate link among all parties concerning the plan of care management

monitor/ reporter

Provides information to parties on status of member and situations affecting client safety, care quality, and client outcome, and on factors that alter costs and liability

Rural- Urban Continuum

Rather than seeing rural and urban residencies as opposing lifestyles; ranging from living on a remote farm, to village or small town, to a larger town or city, to a large metropolitan area with a core inner city

appropriate technology

Refers to affordable social, biomedical, and health services that are relevant and acceptable to individuals health, needs, and concerns

demand management

Seeks to control use by providing clients with correct information and education strategies to make healthy choices, to use health and health seeking behaviors to improve their health status, and to make fewer demands on the health care system

Federally Qualified Health Centers (FQHCs)

Supports a primary care centers efforts to serve low income and uninsured populations and remain fiscally solvent; Receive federal grant funds from HRSAS to support operational expenses; Receive cost based payments for services provided to Medicare and Medicaid patients

facilitator

Supports all parties in work toward mutual goals

Program Evaluation

Systematic approach to improve and account for public health and primary care actions; Separates what is working from what is not and enables clinicians, faculty, and students to ask difficult questions and handle pressing challenges

Multilevel interventions

That acknowledge organizational, environmental, health, economic, and social policy contributions to health, health problems and issues of access to care

tools: action guides

The community health promotion hand book. In collaboration with the partnership for prevention program, the CDC has developed a set of how to guides for five community level health promotion strategies related to its chronic disease prevention target areas of diabetes self management, physical activity, and tobacco use cessation.

Outcomes and quality indicators

These data are presented to the nursing centers board, funders, and the community at large and document the centers contributions to the health and welfare of the community

critical pathways

Tool that specify activates providers may use in a timely sequence to achieve desired outcomes for care; The outcomes are measureable and the pathway tools strive to reduce differences in client care

equity

Treating everyone like you would want to be treated; implies providing accessible services to promote the health of populations most at risk for health problems

Community assessment

Understanding the systems involved in a town or city; some have majors or city counsels, others don't have any cause they are incorporated

telehealth

Uses a variety of technology solutions such as a health care providers, or accessing advanced or continuing education offered by a university located some distance from the receiving site. Nurse must be computer literate and be proficient in using the communication technology that is available

consultant

Works with providers, suppliers, a the community, and other case managers to provide case management expertise in programmatic and individual applications

Advanced practice nurses

additional education and training beyond their basic nursing program; Certified or licensed in a specialty; Responsible for oversight of clinical staff, program services, and outcomes measures; Responsible for assessing population needs, developing grant proposals to expand services, and managing contracts for preventative and intervention programs

rural adults seek less medical care

attributed to scarce resources and lack of providers

National Nursing Center Consortium (NNCC)

can share and support each other; Non- profit academic settings, close with schools of nursing

rural children

cared for by general practitioner who is identified as their usual care giver

Comprehensive Primary Health Care Centers

centers also serve as the primary care home for families; Deal with physical and behavior health care services; Address the needs of individuals and families across the life span; typically hire NP

Nursing center models

combine people, place, approach, and strategy in everyday life to develop appropriate health interventions

Strategic plan

complements business plan; Looks into the future and guides the work for the nursing center; Regular timeline and planning meetings

Business plan

considers all aspects of establishing a nursing center and describes the development and direction of the center and how goals will be met; Built on known sources of funding at the time the plan is developed- Medicare and Medicaid, and Grant supplement

COPHC

effective model for delivering available, accessible and acceptable services to vulnerable populations living in medially undeserved areas; blends primary care, public health and prevention services; interprofessonal uses a problem oriented approach and mandates community involvement in all phases of the process

areas of action: reorienting health services

emphasis on prevention where you work to promote health and prevent disease; the responsibility for health promotion is shared by individuals, community groups, health practitioners, institutions and the government

technology and information systems

essential for data collection and analyses; Need to be used to collect, collate and analyze data and to support the provision of quality health care services; will continue to change and adapt

areas of action: building public health policy

focus on lowering speed limits, enforcing helmet use, no smoking policies; health must be on the agenda of policy makers at the local level

rural populations; specialist are few

have higher infant and maternal morbidity rates because

comprehensive care continuum

health care system creates difficult in providing this to populations living in areas with scares resources; most critically needed services are usually preventative (health screening, nutrition counseling, and wellness education)

Healthy People 2020

how you measure health care in the US; Set goals; Framed national health promotion and disease prevention

assessment

i. Case finding ii. Identification of incentive for target population iii. Screening and intake iv. Determination of eligibility v. Assessment

evaluation

i. Measure attainment of activities and goals of service delivery plan ii. Continued monitoring of client status during service iii. Reassessment iv. Bring closure to care when client needs are achieved or change v. Discharge appropriately

planning for outcomes

i. Problem prioritizing ii. Planning to address care needs iii. Identify resource match iv. Implementation

five rights of case management

i. Right care ii. Right time iii. Right provider iv. Right setting v. Right price

Nurse managed health center

increases assess to care; Provides a more comprehensive approach to health and illness; Decreases racial, ethnic, and geographic disparities in health status; And holds the potential to reduce the overall costs of health care

rural barriers to care

lack of health care providers and services, great distances to obtain services, lack of transportation, lack of telephone services, unavailable outreach services, inequitable reimbursement polices, unpredictable weather/ travel conditions, inability to pay for care/ lack of health insurance, lack of "know how", inadequate provider attitudes, language barriers, care and services not culturally and linguistically appropriate

rural residents

more likely to have one or more of the chronic conditions: heart disease, chronic obstructive pulmonary disease, HTN, arthritis, diabetes, cardiovascular disease, and cancer

rural residents

poor perception of health and functional status, have more chronic illness, physical limitation, and shortage in health care

physical isolation

professional isolation for nurses & scarce financial, human and health are resources & broad scope of practice

community collaboration

requires staff expertise and commitment from many to change communication patterns, professional agendas, and speak in a common voice

research needs

rural nursing deserves more recognition, more info is needed on stressors and rewards, empirical data is needed on nursing needs, international perspective on health of rural populations, most efficient and effective way to use technology in rural care, distance learning, rural- urban disparities in health status and health behaviors (rural context and preferences)

social mandate

social and physical environments

strategic planning

spend time setting a goal and other steps that takes you to get there; Recognizes multiple levels of intervention required for bringing about and sustaining change

CDC Community Health Promotion Handbook

targeted for public health professionals but can be used by community leaders; Divides the environment and focuses into five areas that have an impact on health behavior

areas of action: creating supportive environments

when developing, there should be areas set aside for "green areas" with parks, walking or bike paths, and fitness facilities