1. 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

2. 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

3. 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.

4. 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

5. 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

6. 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

8. 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

9. 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

10. 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

11. 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.

12. 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.

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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