1. Community Plan of Care -
Team One
Community Plan of Care -
Mason County, Michigan
NURS Community Nursing
Carrie Hallihan, Kati Pahssen, Ryan Pienta,
Melinda Routhier, & Erin VanderHorst

2. Mason County, Michigan
Mason County is located on the shore of Lake Michigan, and is famous for world class beaches, Ludington State Park and Manistee National Forest. Mason County has numerous inland lakes and rivers attractive to outdoor enthusiasts that enjoy hiking, biking, swimming and boating. The fertile land and temperate climate allows for commercial fruit and vegetable production. Mason County is a tourist destination with an estimated 20,000 visitors a year. Most of the visitors come in the summer months.

3. Community Assessment
Mason County, Michigan

4. Assessment: Community as Partner Model
Harkness & DeMarco (2012), cite Anderson & McFarlane ( 2004) for the development of the community as partner model, which is an effective tool for a community assessment. “The word “partner” and particularly “community as partner “ is key because it demonstrates the equity of the nurse’s relationship with the community”( Harkness & DeMarco, 2012, p.186). Nursing is an equal partner with the community so it enhances the working together relationship. The community as partner model (Anderson & McFarlane, 2004) is built on the premise that eight parts of the community interact with the population and affect the health of the community. As noted in the model: the community is in the center, the eight parts are: physical environment, health/ social services, economy, transportation/ safety, politics/ government, communication, education, and recreation. The windshield survey, in fact, is based on the community as partner model (Harkness & Demarco, 2012). Using this model as a framework for assessment of the community,both strengths and weaknesses were identified and can be applied to the community plan of care.

5. Community Strengths: Windshield Survey
Cohesive community evidenced by:
Religious activity
Political activity
Environmental protection activity
Numerous local outlets of communication
Local health services by a regional provider
Community commitment to seniors
Public transportation
Educational opportunity, including a community college
Zoning
Evidence of a variety of recreational activities
County and city government activity
Past history of success in solving community level problems
The windshield survey of Mason County identified many characteristics of a cohesive community. With almost 50 churches in the county, residents value and share their religious beliefs. The population is politically active with both the republican and democratic parties having local monthly meetings, active local websites, and active phone lines. Mason County has many lakes and rivers making environmental protection another unifying community value. Mason County has strong communication. The Ludington Daily News online and the print newspaper have a readership of 40,000 people. The paper has an active editorial department that gives a voice to all members of the community. The Mason County Press is a free daily online publication. There are 2 radio stations in Ludington and there is free Wi-Fi in most of the public parks, municipal buildings, and many businesses. Spectrum Health recently formed a partnership with the community hospital. Spectrum brings strength to this small community by increasing access to healthcare and reducing the cost of healthcare. Mason County has an aging, rural population. These are both vulnerable populations at risk for health disparity ( Harkess & Demarco, 2012). Ludington, and surrounding townships are a retirement destination. There is an abundance of affordable senior friendly housing that allows for seniors to age in place. There are four active senior centers throughout the county. The Council on Aging and the people of Mason County financially support the centers through a voter approved millage. There is affordable public transportation available 7 days a week in Ludington, Scottville, and 2 of the surrounding townships. Currently an effort is underway to broaden access to mass transportation, as part of the community plan to improve access to health care. Improving services to the homeless, victims of domestic abuse, and veterans are all past community projects. The success of these past population focused initiatives indicate a strong chance that a multidisciplinary community health plan to improve the health status of Mason County residents should be effective.

6. Who Can Help With a Community Plan of Care:
Physician
Acute care nurses
Social workers
Pharmacists
Psychologist: Community Health
Business leaders
Religious leaders
Philanthropists
Non- Profits
Community Health Department #10
Spectrum Health Ludington Hospital
Hospital administrators
Mason County Intermediate School District
West Shore Community College
Law enforcement
County commissioners
City council
Ludington Daily News
Radio Stations
The windshield survey identified a broad range of strong community members, and organizations that could participate in the community plan of care. Resources such as retail, education, government, social services, religious, philanthropists, and health care providers all have a point of view, and potential for contribution that is crucial in community level problem solving. Philanthropy groups such as Pennies from Heaven, and Help Ministries are local non-profit agencies that have served the community well with past problem solving. They should be included because they represent effective cohesive community partnerships whose only function is to help solve community problems. Overall Mason County leaders have a past record of community activism that is supportive of change and share the core values that are the underpinning of a community plan of care that improves the quality of life of the population of Mason County.

7. Health in Mason County: Determinants of Health:
“Factors that affect outcomes of health status, such as physical environment , social environment, health behaviors, and individual health, as well as broader factors such as access to health services and overall policies and intentions” (Harkness & DeMarco,2012,p.45).
The community health assessment of Mason County identified that the population struggles with health disparities related to these determinants of health.
The health status of Mason County is described in the District Health Department #10 Health Profile Chartbook. The Chartbook is based on the Healthy People 2020 framework.

8. Demographic Determinants:
Mason County Population is Aging, Rural, and not Diverse.
(US Census, 2014)
According to the US Census (2014), Mason County has a significant aging and rural population. These are both vulnerable populations at risk for health disparity, ( Harkess & Demarco, 2012). Ludington, and surrounding townships are a retirement destination. Seniors are attracted to this area for many reasons. There is plenty of affordable senior friendly housing that allows for seniors to age in place. There are four active senior centers throughout the county. The Council on Aging and the people of Mason County financially support the centers through a voter approved millage. There is affordable public transportation available 7 days a week in Ludington and Scottville, but only 2 of the surrounding townships choose to participate in this service. Consequently, some rural residents may find themselves isolated due to lack of transportation, lacking access to health services. According to Harkness & DeMarco (2012), lack of diversity can lead to ethnocentric policies and behaviors that could place hispanic community and other minorities at increased health risk.
(District Health Department #10, 2013)

9. Economic and Educational Determinants of Health Disparity
Mason County struggles with poverty. According to the District # 10 Health Department,(2013) the median household income is approximately $8,000, less than the state median income. Medicaid births and the use of free/ reduced school lunches also support the existence of poverty in the county. Poverty is a barrier to higher education, access to healthcare and the ability to participate in healthy behaviors.
People per primary care provider in Mason County is 1436, compared to Michigan at One reason rural areas are underserved is many physicians are not attracted to rural areas (Harkness & DeMarco, 2012). Lack of primary care physicians causes providers to be over burdened with patients. The quality of care patients receive is negatively affected because the doctors are forced to use most of a visit dealing with the acute patient needs, not offering counseling regarding healthy lifestyles and health promotion( Karmeisool, E., 2015). Poverty is another barrier to health care in Mason County, directly related to due to joblessness, and lack of education. Often people living in poverty cannot afford health insurance.
(District Health Department #10, 2013)

10. Health Behaviors Cause Health Disparity
(District Health Department #10, 2013)
The higher than expected overweight population could be related to the aging population and could contribute to diabetes and cardiac disease. Overweight and smoking could both correlate with Mason County’s overarching problems of poverty, rural populations, lack of education, and other barriers in accessing health care services.

11. Summary: Mason County Health
Weaknesses:
Demographic: rural and poor area, under educated population, and aging non diverse population
Access to health care: uninsured, lack of primary care providers, and high cost of health care
Health indicators: high mortality rate, cancer, diabetes, smoking, overweight, smoking during pregnancy
Strengths:
Low incidence of cancer, cardiovascular mortality
Low obesity, infant mortality
Adequate fruit and vegetable consumption
Adequate physical activity
Based on the District Health Department # 10, 2013, Chartbook, Mason County does have health strengths related to healthy behaviors and environmental factors that are known to affect population health. The consumption of fruit and vegetables, adequate leisure time, and physical activity are vital health promotion activities. Mason County has numerous walking, hiking, and biking areas. Year round outdoor activity is common. There are 3 private gyms and 2 public swimming pools. The greater Ludington area is a walkable city with many new wide sidewalks and bike lanes. Mason County leaders are actively working toward improving access to health care and Spectrum Health is a leader in the process. Another community asset that could directly affect healthy eating is that Mason County is a food producer for the nation. Fruit and vegetable farms are abundant, making locally grown produce affordable and readily available for several months of the year. Mason County schools require physical education and are mindful of the quality of the food they serve the students. The schools have targeted childhood obesity as a risk for students and are establishing plans to increase health promotion in the schools. There are many sports complexes around the county indicating a level of participation in youth sports and community support for these activities.
Weakness in the demographic mix, access to health care, and some health behaviors resulted in negative health outcomes for the Mason County population.

12. A Salient Problem: Smoking
Scope of the problem in Mason County:
24.3% of the population smoke, more than Michigan: 20.3%, more than Healthy People 2020 target:12%.
Leading causes of death in Mason County:
Heart disease: higher than District 10 and Michigan
Cancer: higher than Michigan
Chronic lower respiratory disease: higher than District 10 and Michigan
Stroke: higher than District 10 and Michigan
(District Health Department # 10 , 2013)
Prevalence of lung disease in Mason County:
Pediatric Asthma: 571 cases
COPD: 1,836 cases
Adult Asthma: 2,330 cases
Lung Cancer: 20 cases
American Lung Association ( 2014)
Smoking is the leading cause of preventable death in America (CDC, 2012). Smoking is a risk factor for all four leading causes of death in Mason County. The rate of chronic lower respiratory disease is especially significant: Mason County rate is 61.2 deaths/ 100,000 , District deaths / 100,000, and Michigan is 45.9 deaths / 100, 000 people. This is a significant difference that could be affected by a higher than expected rate of smoking in Mason County. Exposure to secondhand smoke is known to be dangerous. Pediatric asthma may be related to exposure to secondhand smoke. Many people could be positively affected by a reduction in smoking

13. Why The Disparity In Mason County:
The Health Belief Model:
Healthy behavior dependent on four concepts
The severity of the potential illness or physical challenge
The level of conceivable susceptibility
The benefits of taking preventative action
What stands in the way of taking action toward the goal of health promotion.(Harkness & Demarco, 2012, p.77)
Current Resources:
Lack of Educational Based Resources
Lack of Community Health Based Resources
Lack of Law Enforcement Assets
The Mason County Plan of Care uses the health belief model as a framework for change. According to the health belief model, in order for behavior change to occur people need to have an understanding of how bad unhealthy behavior can affect their health and understand that they are vulnerable to the dangers the unhealthy behavior poses. People must also believe that stopping the unhealthy behavior will be very beneficial to them. Lack of health promotion education can prevent synthesis of these concepts. Over-burdened Mason County primary care providers are busy addressing acute health needs, and are not able to take the time to counsel and educate patients regarding healthy behaviors (Karmeisool, 2015). Poverty, rural dwelling, and lack of education are barriers to healthcare that can prevent a change in behavior. Cultural and social factors affect health behaviors in the young. There are multigenerational families that smoke allowing young family members to think this behavior is normal. Peer pressure can lead to children participating in unhealthy behaviors. Finally, Mason County’s lack of diversity can produce ethnocentric health care policies and processes that are barriers to behavioral change for hispanic and other minority populations. The Mason County community does not have enough law enforcement assets to dedicate to anti tobacco activity, such as the use and sale of tobacco to minors, and smoking in unlawful areas. According to Harkness & DeMarco (2012), upstream policies such as the use of legal action, are very effective in changing health behaviors.

14. Evidence Exists that Smoking is Appropriate for a Community Nursing Intervention
Community health nursing focuses on health promotion, disease prevention, and risk reduction (Harkness & Demarco, 2012).
Tobacco is a risk factor for cancer, heart disease and other leading causes of death.
The literature suggests nurses can make a difference:
Public health nursing plans affect change in communities, (Kulbok, Thatcher, Park and Meszaros, 2012)
The literature is rich in evidence of the role nursing plays in affecting behavior change in people and communities. Kulbok et al., (2012) article describes smokers as a vulnerable population. This study also discusses the transition public health nursing has made towards more of a leadership role. Using professional competencies that allow nurses to lead multi disciplinary/dimensional teams and making community level changes can affect the population of the community. A community level plan for smoking cessation is well suited to community nursing.

15. Diagnosis
Mason County, Michigan

16. Population most likely to smoke:
Men are more likely to smoke than women
Aged 25-64
White
Less educated
Poor
(CDC, 2013)
According to the CDC, the most affected by smoking are men age 25-64, white, less educated, and poor. Mason County has a population at higher risk for smoking.

17. Mason County - Community Focused Nursing Diagnosis
Based on the strengths and weaknesses of Mason County:
Community Diagnosis:
Risk of heart disease, cancer, chronic lower respiratory disease, and stroke. (District Health Department #10, 2013)
Among men more likely than women, aged 25-64, poor, and less/under educated. (CDC, 2013)
Related to smoking

18. Mason County - Community Focused Nursing Diagnosis
As demonstrated by:
Leading cause of death in Mason County is heart disease 202.5/100,000 as compared to Michigan at 201.6/100,000. Cancer runs second leading cause with 185.6/100,000 as compared to Michigan at 177.2/100,000. Chronic lower respiratory disease 61.2/100,000 with Michigan at 45.9/100,000. Stroke coming in fourth with 53.8/100,000 compared to Michigan at 38.7/100,000. statistics for population of Mason county who currently smoke are also high with 24.9% compared to Michigan at 20.3%.
(Michigan Department of Community Health, 2011)
Delayed intervention and lack of health promotion activities related to poverty, lack of access, and lack of education could result in higher than expected mortality rates. Spectrum Health Ludington Hospital has a cancer center that provides cancer care to the community. The rural, poor, and poorly educated population may not gain access to the cancer center. Patients needing advanced treatment are referred to Grand Rapids or Muskegon. The travel required for these referrals may be a barrier for the poor, diverse, and less educated population.

20. Planning & Interventions
Mason County, Michigan

21. Mason County - Planning & Interventions
Possible community interventions based on our diagnosis:
•Health education programs
•Screening & information, referral
•Establish services
•Set policy & implement
•Community self-help & empowerment
•Changing power structures

22. Intervention Incentive Program
Modeled from NYC Health eQuits Program funded by CDC
Showed cessation interventions increased from 20% to 64%
Work with local community health centers
Spectrum Health, District 10 Health Department, West Michigan CMH
Ask to document smoking status in patients’ EMR
Ask to document smoking cessation interventions
Qualifying interventions (physician counseling, cessation medication prescriptions, and quit hotline referrals) will reward health center with a monetary incentive, based on available funding
Request health centers to reinvest that money into their smoking cessation programs and interventions
Enables us to increase smoking cessation interventions, but difficult to monitor success rates
A New York City program called Health eQuits, which was funded by the CDC, rewarded community health centers $20 for each smoking cessation intervention they implemented. This program was targeted to the Medicaid population, which has higher rates of smoking status in NYC. Similarly, the most at risk in Mason county are the poor and less/under educated.
Depending on funding, we would initiate a similar program in Mason County. We would work with local community health centers to incorporate smoking status of patients into their electronic medical record, if not already in place. We would also establish specific qualifying interventions that would reward the center with a monetary incentive, based on available funding. This program would encourage centers to address smoking status and implement cessation interventions. It would also allow us to assess the number of clients who do smoke and the interventions they have been given. In NYC, interventions increased from 20% of smokers receiving them to 64%. However, the program does not allow for easy monitoring of success rates. (Centers for Disease Control and Prevention, 2014)
Centers for Disease Control and Prevention. (2014). Increases in smoking cessation interventions after feedback and improvement initiative using electronic health records. Morbidity and Mortality Weekly Report. 63(41) Retrieved from
(Centers for Disease Control and Prevention, 2014)

23. Funding
Funding will be acquired through grants made available from the following local organizations:
Pennies from Heaven
United Way of Mason County
Community focus area: “Obtain and maintain a healthier lifestyle through diet and exercise and decrease the rate of substance abuse” (United Way of Mason County, n.d., para. 3).
Community Foundation for Mason County
Funding area of interest: “Promote healthy lifestyles through education and prevention programming” (Community Foundation for Mason County, n.d., para. 6).

24. Mason County - Implementation of Plan
Our team’s proposed plan of action is put into play. This will occur over a set period of time and then we will revisit to evaluate how effective our plan was in comparison to our goals and objectives.
We will need to help the healthcare facilities in Mason County to institute assessment of smoking statues of their patients to find how much of the population is smoking.
From this we may identify a target age group or population who smoke more
than others. Based on these findings there may be ways to better target this select population.
We will need permission from other facilities to participate in our project.
Resistance to change is normal; collaborate, coordinate, and consult with others in healthcare to stop smoking in Mason County.

25. Plan: How do we stop the public from smoking?
Address smoking status of individuals on all medical records - current smoker, former smoker or passive smoke exposure.
Spread the word! Post images, flyers, educational handouts describing what smoking can do to one’s health.
Use social media to spread “STOP SMOKING!” (Facebook, Instagram etc.)
Show images of health lungs and heart vs. heart and lungs of smokers.
Make the current smoking cessations programs more well known in Mason County.
Programs already in place within schools, churches and hospitals.
Online Smoking Cessation Programs

26. Smoking Cessation Inform the public on ways to stop smoking:
Decide to quit and make a plan!
Medication -Nicotine replacement
(Nicorette gum/patches/E-cig)
Exercise & healthy diet
Smoking cessation groups/meetings, family & friend support
Rewards of quitting smoking-
Better overall health (heart & lungs)
Decrease likelihood of cancer
Whiter teeth, better tasting foods, distinct smell goes away from clothing, and no more yellow fingernails

27. Evaluation of Plan
Mason County, Michigan

28. Mason County - Evaluation of Plan
After implementation has occurred, the desired outcome would be that over a period of time (let’s give 3 months), we would eventually see a decrease in smoking among the community. Overall, we want to see less people smoking after we’ve given time for our implementation process to occur. “Ultimately, the health program ought to have an effect on the health of the individual program participants or on the recipients of the program intervention if provided to the community or a population” (Issel, 2004, pg 13).
Evaluation of how effective our plan was can be measured by:
The percentage of the community that go forward with smoking cessation interventions compared to those who do not within the community.
Sending out surveys to those who visited in the hospital, asking how their smoking cessation is going after nursing/health care associate interventions.
Completing phone call backs to those who visited in the hospital and/or community health centers, asking how their attempt at quitting smoking is going.
Observing people’s behavior and response to education given.
Head count of those involved with education programs, school assemblies, church programs, hospital programs, and services available.
Monitoring smoking status when admitting patients into the hospital using the smoking questionnaire per patient’s EMR.
Monitor smoking status of patients being seen in the local community health centers.
Checking the status of a Facebook page that was started to help advocate and support those interested in quitting smoking.
Visiting local stores to see if they have experienced a drop in tobacco sales.

29. Mason County -Evaluation of Plan
Our goals and objectives for this plan were met as evidence by:
Short-term
Less people are smoking within the community from random polls, callbacks, surveys, etc. that were completed, compared to before starting the community plan of care.
Increased interest and positive behavior in smoking cessation among the community.
The number of people interested in additional information, resources, and their eagerness of spreading the word to others in the community has increased.
Length of days a recent smoker has not smoked has increased since their last use (pick random sampling from the population to assess patient smoking status).
Increased interest (likes or shares) on Facebook support page.
Local stores have seen a decrease in selling smoking products (monitoring local sale of tobacco).
High level of attendance within the smoking programs offered, with continued interest going forward.

30. Mason County -Evaluation of Plan
Our goals and objectives for this plan were met as evidence by:
Long-term
Patients who revisit the hospital or community health centers show positive results (their smoking cessation is working and they haven’t touched a tobacco product since their last visit when being admitted or seen by healthcare professionals)
Blood pressures have decreased among patients who formerly smoked and were part of this community plan of care
Decreased heart and lung disease, cancer, and stroke percentages over the entire community, compared with percentages before implementing the community plan of care
Increased energy and ability to exercise among patients who formerly smoked
Money saved by individuals from not buying tobacco products
Overall health of the community has improved compared to before the community plan of care was implemented
At the end of the evaluation process, we can discuss what went well with the community plan of care against quitting smoking and what can be improved. “The evaluation of the effect of the program provides data and information that can be used to alter the program interventions. These findings can also be used in subsequent assessments of the need for future or other health programs” (Issel, 2004, pg. 13). It would be beneficial if we could get representatives from the local health facilities (community health centers, hospitals, etc.) and schools, churches, local organizations, etc. to attend a meeting where we can discuss this further (consider it like an interdisciplinary meeting). The plan of care can always be improved and make it more appealing to the community who truly want to take back their life and kick the smoking habit.

31. Conclusion
Our goal is to increase awareness of smoking cessation in Mason County, as well as decrease the percentage of smokers within the county.
Through community interventions like health education programs and working with local healthcare facilities we were able to promote smoking cessation within Mason County.
Some goals met in our short three month period were an increase in public interest in regards to wanting information regarding smoking cessation.
We hope with further education and smoking cessation within Mason County, we will be able to see a dramatic decrease in the number of smokers in the coming years.

32. References
American Lung Association, (2014). Estimate prevalence and incidence of lung disease. Retrieved from
Centers for Disease Control and Prevention. Current smoking among adults in the united states. Retrieved
from
Centers for Disease Control and Prevention. (2014). Increases in smoking cessation interventions after
feedback and improvement initiative using electronic health records. Morbidity and Mortality Weekly
Report. 63(41) Retrieved from 1a2.htm
Community Foundation for Mason County. (n.d.). Grant priorities. Retrieved from
District Health Department #10, (2013). Health profile chartbook 2013: Mason County. Retrieved from
Harkness, G. & De Marco, R. (2012). Community and public health nursing: Evidence for practice.Philadelphia, PA. Lippincott
Williams & Wilkins

33. References: continued
Issel, M.L. (2004). Health Program Planning and Evaluation: A Practical, Systematic Approach for
Community Health. Sudbury, MA: Jones and Bartlett Publishers
Karmeisool, E. (2015, January 17). Bridging the gap: A talk with dr. ryan.The Ludington Daily News, pp A1, A5.
Kulbok, P.A., Thatcher, E., Park, E., Meszaros, P. S. (2012) Evolving public health nursing roles:
Focus on community participatory health promotion and prevention. OJIN:The Online Journal of
Issues in Nursing, 17(2). doi: /OJIN.Vol17No02Man1
Spectrum Health (n.d.). Implementation plan for needs identified in community health needs assessment
for memorial medical center of west michigan.Retrieved from
United States Census Bureau (2014). Population estimate july 1, ludington/ mason county michigan/ michigan. Retrieved from
United Way of Mason County. (n.d.). Community focus areas. Retrieved from