Community-Based HealthCare PPP by Marianne McAuley , BSN, MS, RN Revised KBurger1008 LECTURE # 20 FALL 2009 By using public health principles, the nurse is able to better understand the types of environments in which clients live and the types of interventions necessary to keep clients healthy. Healthy communities –healthy people – healthy nation

What is Community-Based Health Care? Part of holistic nursing practice Focuses on primary health interventions – [ preventative health care ] Considers unique needs of a specific geographic region and population of that community. Diverse settings – rural, urban, etc. Care provided to people who live in a specific geographic area - PHN-Hempstead Care to people with common needs - TB follow-up, Sr. Citizens Many different types of settings hospitals, long-term care, clinics, home care, doctors offices, schools, day care centers, Elder-care Centers

HEALTHY PEOPLE 2010 Health care goals for the nation Increase quality & years of healthy life for Americans Remove disparities in health care The US Department of Health & Human Services Public Health Service designed this program to improve the overall health status of people living in this country. Emphasizes link between individual health & community health. The health of the community determines the health of the nation The healthy people initiative was initially created in 1990 to establish health care goals for the year 2000. In 2000 these goals were revised for 2010. 2 overarching goals for 2010: Increase quality & years of healthy life for Americans 2. Remove health care disparities Is the higher rate of breast cancer mortality in black American women in contrast to white American women due to decreased access (disparity ) to mammograms.

PUBLIC HEALTH NURSING Understand needs of a population PUBLIC HEALTH PROBLEMS Prevalence of overweight Under immunization of children Increase of STD Drug resistant strains of TB Toxic environmental conditions New diseases - AIDS, West Nile Virus BMI on assessment form 25-29 = overweight >30 = obesity

Components of a Community Assessment Population Demographic census data Predominant cultural group Structure Location of services Locations where people congregate Housing economy Social System Transportation system Health system – gaps in services? Government

Types of Preventive Services Primary: Decrease risk to a client for disease life-style modifications Secondary: Early intervention to alleviate disease Diagnosis & prompt intervention to decrease severity of a disease screenings Tertiary Minimize effects of chronic conditions rehabilitation activities Primary: can be an individual or community Traditionally US health care focused on disease prevention Shift to health promotion Lifestyle modifications: smoking cessation, diet education, weight reduction, immunizations, safe environment (seat belts, side air bags, smoke detectors) Secondary:early detection & interventions screenings, acute care, surgery Tertiary:rehab activities to obtain optimal level of functioning:MI: cardiac rehab, Stroke

National Public Agencies U.S. Dept. of Health & Human Services administratively responsible for public health care services U.S. Public Health Services oversees delivery of public services Veteran’s Administration health care for members of armed forces Financed with Federal tax dollars

Agencies of USPHS CDC- prevents transmission of communicable diseases FDA - Protects public from unsafe drugs, food, cosmetics NIH – National Institute of Health conducts research & education for specific diseases AHRQ – Agency for Health Care Research & Quality identifies standard of care for high-volume diseases CDC: Anthrax management, Standard Precautions,Flu vaccines,West Nile Virus – spraying NIH: stroke AHCPR: committee of experts protocols: pressure ulcers, pain

State and Local Health Departments New York State Department of Health NYSDOH Suffolk County Department of Health SCDOH Financed with state tax dollars Each state varies in provision of public health services L.I.: Nassau & Suffolk Health Depts.: clinics: maternal-child, TB

Voluntary Agencies ANA, AMA American Heart Association American Cancer Society Meals on Wheels Support Groups As a nurse with a community focus, you want to be aware of the services of community agencies. These are a resource that you can use to assist clients with their needs. We hope that this is 1 outcome of this community project. ANA, AMA: legislative influence ACS, AHA, ADA: educational resources to general public & health care professionals. Example: ACS: Hauppauge, AHAS: Bohemia - send materials Community nurse: collect file of educational materials for clients Support groups: Reach to Recovery, AA, I Can Cope etc.

ROLES OF THE NURSE Caregiver Collaborator Advocate Educator Manager Change agent Counselor Variety of roles independent dependent Interdependent Collaborator – work with interdisciplinary team Advocate – help them walk through system Educator – help clients assume responsibility for their own care. See JCAHCO requirements for discharge Manager – seek new & more effective solutions to problems – evidence-based practice Counselor – identity & clarify health problems. Direct to appropriate resources.

FINANCIAL ASPECTS OF HEALTH CARE US: private insurance model Past: Retrospective System: fee-for-service Present: Prospective System: predetermined fixed amounts of payments Managed Care Payment System: 1983: Prospective Diagnosis Related Groups (DRGs) Length of Stay (LOS) Reform in health care motivated by health care costs US spends more on health care than any other nation, yet not all citizens have health care coverage PAST: Retrospective: provider billed whatever it cost - no incentive for cost-control. Cost-based system. Costs of health care spiraling out of control 1983 Congress established the PPS – this eliminated cost-based reimbursement Prospective: receive set amount - based on DRGS Control of costs shifted from health care providers to insurers

Managed Care access, cost & quality are controlled emphasis on prevention & primary care not a place, but an organizational structure primary care physician - gatekeeper System of providing & monitoring care Goal: delivery of services in most cost-efficient manner Monitors delivery of services - quantity restricts access to expensive procedures & providers Primary Care Physician: gatekeeper referral to see specialist

Types of Managed Care Managed Care Organizations (MCO) - Staff model = physicians employed by the MCO - Group, Network, Independent model = MCO contracts with specific practitioners or groups capitated rates: a preset flat fee based on membership not services referral needed for specialists Rationale: give consumers preventive services by a primary care provider Prevent problems or minimize their impact means better health for the consumer & less money spent on health care problems Need a large membership: collects more money – so it will cover costs of services to members Patients with low-cost health care needs offset cost of those with high cost health care needs

TYPES OF MANAGED CARE PPO [ Preferred Provider Organization ] - members use network of providers - insurance plans and self-insured employers members pay extra for providers outside of network incentive for providers: large # of patients 42% growth rate in last 10 years Network of Providers: pay co-pay only usually Outside of network: annual deductible PPO pays 80% of reasonable & customary charges

MEDICARE A type of MCO Part A: inpatient hospital, skilled nursing facility, home, hospice care no premium - paid by Federal gov’t Part B: outpatient costs, physician visits paid by monthly premium Part D: [ as of 1/06] prescription coverage Part D: [ as of 1/06] prescription coverage 1965:Federal health care program for those over age 65 1972: expanded to permanently disabled & dependents & ESRD Medicare does not cover full cost of certain services – supplemental insurance recommended. Prospective payment system – fixed fee for DRG: THR, CHF. Co-morbitities factored in Part A: no cost. Must be a US citizen or resident with a visa who has been here for 5 consecutive years SNF – skilled care from a licensed nursing staff. Medicare covers 100 days but at a decreasing dollar amount after the first 20 days. Part B. Monthly premium deducted from Social Security check - $88/month Part D: As of 1/06 provides limited coverage for prescription drugs Select a Rx plan, meet a deductible

MEDICAID For people with low income Jointly administered by Federal government & states Each state determines eligibility & services 90% of long-term care (nursing centers) paid by Medicaid NYS has different criteria for eligibility & provides different services than Florida Steady increase in # of older adults Major concern for financing of LTC Medicaid is the largest payor Taxes would continue to increase Long-term care insurance is expensive

ISSUES IN HEALTH CARE Cost oversupply of specialized providers focus on treatment of disease, not prevention surplus of hospital beds consumers are passive aging of population advanced technology lawsuits Costs rising at 10% a year Far above inflation rate Health Care Costs; 15% of GNP US spends more on health care than any other country Resources fixed: moved from other areas: defense,education etc. Hurts American businesses, especially small companies - can’t compete in global market

ISSUES IN HEALTH CARE Access more likely to develop health problems poorer outcomes Vulnerable Populations -Poor -Homeless -Abused -Substance Dependent -Elderly -Immigrant -Mentally Ill Proper assessment requires non-judgmental and culturally competent attitudes. Critical thinking! Access: ability to pay & geographic location of facilities Vulnerable: Those who are more likely to develop health problems as a result of excess risks ( adolescent pregnancy), who have limits in access to health care services (poor, homeless, new immigrants), or who are dependent on others for care ( older adults). Poorer Outcomes: higher mortality rates, shorter life spans