NURSING IN THE COMMUNITY

NURSING/HEALTH CARE IN THE COMMUNITY

STUDY MATERIAL

2016

HEALTHCARE IN THE COMMUNITY

PURPOSE:

The purpose of this offering is to provide the healthcare professional with an understanding of concepts and theories related to community health care. This course consists of home study materials and components.

OBJECTIVES:

Upon completion of this course, the learner will:

1. Describe the evolution of community-based care.

2. Identify community-based care concepts.

3. Explain health promotion and health prevention initiatives.

4. Define the roles of the healthcare professionals in the community.

5. Describe policies, procedures and documentation required for conducting a home health visit.

1 INTRODUCTION

History of Community Health

An understanding of care in the community can be traced back to ancient Greek mythology. was the goddess of hell and her sister was the goddess of healing. Public health practices and community health practice have evolved since the 1900s and includes working with vulnerable populations in diverse settings. These settings include schools, homes, shelters, worksites and neighborhood outpatient treatment centers.

Public health nursing commenced in the United States on a minimal basis; affluent women hired nurses to visit the indigent sick in their homes. By 1910, the work of these nurses had expanded to include a variety of preventive programs. Initially, most preventive programs started with voluntary organizations, such as the Eventually, a differentiation existed, the voluntary organizations were eventually taken over by boards of education or health departments. This separation of the care of the poor sick resulted in nursing care coming under the domain of voluntary organizations, while education on prevention became the responsibility of public agencies.

COMMUNITY BASED CARE CONCEPTS

A community is a social group of any size whose members reside in a specific locality, share government, or have a common cultural and historical heritage. This may include social, religious, occupational, or other groups sharing common characteristics or interests or working toward common goals. The patient focus may be an individual, particular group, family, or an at-risk population.

Community-based health care is a system that provides health-related services within the context of people’s daily lives. In contrast to the traditional health care system that focuses primarily on the ill and the injured, community-based care is holistic; involving a broad range of services designed not only to restore health but also to promote health, prevent illness, and protect the public.

To be most effective, a community-based health care system needs to

1) provide easy access

2) be flexible in responding to the care needs of individuals and families

3) promote continuity of care between and among health care agencies

4) provide appropriate support for family caregivers.

Community-based nursing may occur in the home, ambulatory care (clinic) setting, schools, correctional facilities, residential settings (e.g., assisted-living settings), occupational work sites, shelters, or on the street.

Home care may consist of a visiting nurse coming into the home for assessment and evaluation once or twice per week, daily for intravenous therapy, or even include care provided by a nursing assistant to meet the patient’s daily needs (e.g., bathing).

1. DISEASE PREVENTION-LEVELS OF PREVENTATIVE CARE

Epidemiology is the study of the occurrence, incidence, and causes of the occurrence of disease (illness and injury) in populations, and the application of this study to the control of these health problems. Epidemiology is concerned with the traditional study of epidemic diseases caused by infectious agents (e.g., Tb), and with health-related phenomena, including accidents, suicide, climate, toxic agents such as lead, air pollution, and catastrophes due to ionizing radiation. Terms that are important to know and understand when discussing epidemiology include primary, secondary, and tertiary prevention and care, endemic, epidemic, pandemic, frequency rates, incidence, prevalence, and morbidity and mortality rates.

Preventive healthcare activities are defined as primary prevention, secondary prevention, or tertiary prevention. Nursing and other health services are classified by types of care according to increasing complexity. Primary health care includes health promotion, preventive care such as immunizations, health education, environmental protection, and early detection and treatment. Secondary healthcare includes emergency care, diagnosis and treatment (complex), and acute care. Tertiary care includes long-term care, care of the dying, and rehabilitation.

PRIMARY

Primary prevention involves eliminating the modifiable risk factors for certain disease processes or potential health hazards. These can include smoking cessation programs or targeting children and teenagers to discourage smoking before it begins (e.g., teaching healthy lifestyles). Primary prevention also includes activities such as following a low-fat diet to help prevent the development of atherosclerosis. Eating a diet low in refined sugar is a primary prevention activity to avoid dental caries and obesity in all age groups. Using condoms is a form of primary prevention to avoid sexually transmitted diseases. Immunizations administered on the recommended schedule are another method of primary prevention. The goal of primary prevention is to decrease the risk of a potential condition occurring in a person or group of people to the greatest extent possible.

SECONDARY

Secondary prevention is the use of health screening to detect the presence of certain diseases, risk factors, or predisposition to select conditions. Health screening activities include the annual Papanicolaou screening test (Pap smear test) for women to detect the presence or precursors of cervical cancer. Monthly breast (for women) and testicular examinations (for men), and regularly assessing the growth and development of children are examples of secondary prevention. These activities do not prevent the onset of disease or disorder. The goal of secondary prevention is to catch pre-disease states or the beginning stages of diseases so that early treatment can be instituted and hopefully cure the disease.

TERTIARY

Tertiary prevention is treatment and rehabilitation after an individual actually has contracted a disease. An example of tertiary prevention would be treating a breast cancer patient with a partial mastectomy, chemotherapy, and radiation. The patient would then engage in physical therapy to regain full use of the affected arm, plus have follow-up screening blood tests to detect the return of the disease. Other examples of tertiary prevention include referring a patient with hypertension to a stress-reduction group and teaching a patient how to prevent complications of a disease such as the sequelae that often occur in diabetics. The goals of tertiary prevention are to rehabilitate the patient during and after treatment to the highest functioning possible, and prevent sequelae or further deterioration due to the disease process.

2 Key Community Health Terms

An epidemic is an infectious disease or condition that attacks many people at the same time in the same geographical area.

A pandemic disease is one affecting the majority of the population of a large region, (e.g., dental caries or periodontal disease), or one that is epidemic at the same time in many different parts of the world (e.g., HIV/AIDS).

An endemic condition or disease is one that occurs continuously or in expected cycles in a population, with a certain number of cases expected for a given period (e.g., influenza and the common cold).

The terms frequency, incidence, and prevalence can be used interchangeably, and essentially mean the number of cases of a disease present in a specified population at a given time.

The terms morbidity and mortality are often used together, morbidity meaning the number of sick (or injured) persons or cases of disease in relationship to a specific population (e.g., per 1,000 persons) and mortality meaning the death rate or the ratio of the number of deaths to a given population.

Communicable diseases are caused by those infectious agents that can be transmitted to an individual by direct or indirect contact, through a vector or vehicle, or as an airborne infection. Infectious diseases are the major cause of death worldwide, and a leading cause of illness and death in the U.S.

The control of the spread of microorganisms and the protection of people from communicable diseases and infections are carried out on the international, state, community, and individual level. The WHO is the major regulatory agency at the international level. In the U.S., the CDC is the principal public health agency at the national level concerned with disease prevention and control. At the state and local levels, health departments track epidemics and illnesses as reports are made throughout the area.

The nurse and other healthcare professional’s role in prevention of the spread of communicable diseases includes frequent hand washing, maintaining aseptic technique when providing patient care, following isolation policies and protocols when indicated, and educating the client, family, and other members of the healthcare team. Community health workers play important roles in collecting data, making diagnoses, reporting cases, and providing feedback information to the general public.

Examples of possible activities for the nurse include investigating sources and contacts in outbreaks of diseases, such as measles in school settings or shigellosis in day care; Tb testing and contact tracing. The nurse may also be involved in collecting and reporting information pertaining to notifiable communicable diseases; and providing morbidity and mortality statistics to those who request them (e.g., the media, the public, those planning services, and those writing grants).

Requirements for disease reporting in the U.S. are mandated by state laws and regulations. The list of reportable disease in each state varies. The state health departments report the cases of selected diseases to the CDC in Atlanta, GA. There are over 45 infectious diseases that are designated as notifiable at the national level by the National Notifiable Diseases Surveillance System (NNDSS). Some examples of more well-known reportable diseases are Tb, hepatitis, AIDS, botulism, chancroid, gonorrhea, Haemophilus influenzae, Lyme disease, measles, mumps, rabies (animal and human), Rocky Mountain spotted fever, and syphilis. The nurse can find out if a disease is on reportable list by contacting the local or state health department, the CDC, or reading Morbidity and Mortality Weekly Report (MMWR).

3 NURSING/CARING IN THE COMMUNITY

The goal of Community-based nursing care is to provide for the needs of the patient, to allow the patient to remain living at home, regardless of age or disability. Community-based nursing care is paid for by the government through Medicare and/or Medicaid; private insurance or health maintenance organizations (HMOs) patients themselves, certain non-profit community, charitable disease advocacy organizations or faith-based organizations.

The nurse is a guest coming into the patient’s home or community setting. Nurses have little control over the care environment. Little on-site support or supervision is available. Supplies and resources may not be available.

Key Characteristics of community-based professionals

• Be self-directed

• Be flexible

• Be critical thinkers

• Be independent decision makers

• Have proficient care competencies

• Have excellent assessment skill

• Have good abilities to provide health education

• Be culturally competent

4 Policies, procedures and documentation in Home Health

Different roles are performed in the community health setting. In the home, nurses and other allied health professionals make visits to patients to deliver care. Registered nurses and Physical therapists are authorized to conduct comprehensive assessments to admit patients to home care. These healthcare professionals conduct a patient centered health history and assessment including patients/family’s health, socio-demographic data using the OASIS assessment tool to determine reimbursement for Medicare. RNs or PTs admit patients to home care after determining homebound status.

A collaborative team develops a plan of care (POC) that is signed off/finalized by the primary physician. The POC then guides the delivery of care. Nurses, pharmacists, lab personnel, therapists and other professionals deliver care to patients in the home.

5 Home Health Visit Preparation

In preparation for a home health visit. All healthcare professionals should do the following:

• Review agency policies and procedures

• Review the referral forms and other appropriate records

• Call and arrange an appointment

• Always ask permission and explain the purpose and goals to the patient

6Conducting a Home Health Visit.

Considerations When Conducting a Home Health Visit:

Personal Safety Issues

• Recognize healthcare professional is in “guest” role with the patient as final decision maker

• Prepare for personal safety precautions

• Inform agency staff of planned visit schedule

• Have a working cell phone

• Schedule visits during daylight hours when possible

Assessment-

• Perceived ability to follow the treatment plan

• Ability to self- inject medication as ordered

• Ability to perform wound care as ordered

• Ability to perform ADLs or IADLs

• Child abuse hotline for suspected abuse

• Referral for domestic violence, adult protective services for unsafe living situation or elder abuse

• Considering counseling or psychiatric services regarding coping processes

• Is substance abuse common in the dwelling?

Determine goals and outcomes

• Identification of expected outcomes and development of a patient centered plan of care reflecting nursing interventions that integrate standards of care, protocols, ethics, and laws, and regulations.

• Create a patient centered plan to address patient problems; use technology, when available and appropriate.

• Include interventions related to restoration of health, health promotion and maintenance

Documentation

• Patient response to attainment of expected outcomes

• Has the patient’s condition stabilized or improved?

• Has the patient/family and or caregivers learned to manage the health care needs.

Concluding the visit

• Include patient/family in discharge planning

• Discuss life after home care and anticipated changes

• Educate regarding: process and steps, use teach back techniques to assess patient/family learning, listen to and honor patient family desires.

• Ensure client safety

References

CMS Clarifies Definition of "Confined to the Home" (Homebound) for Medicare Purposes. By: VNAA Policy Team on 11/5/2013

Stanhope, M., Lancaster, J. (2008). Public Health Nursing: Population-

Centered Health Care in the Community. St. Louis, MO: Elsevier