DEPARTMENT OF CLINICAL IMMUNOLOGY, ALLERGOLOGY ANDGENERAL PATIENT CARE
The
After studying this chapter, you should be able to:
· Identify the nursing center.
· Describe profile and examples of the nursing center
· Analyze Caring-Healing Nursing Practice Model
· Describe case management, methodology, functions.
Introduction
As the health care marketplace reconfigures becoming more capitates, more profit-driven, more integrated, and more ambulatory concern is growing in some quarters that the safety net for vulnerable people is changing, too. Whether the safety net is stretched too thin, as some say, or has too many holes, as others say, is open to question, but the numbers of publicly insured, working poor, and uninsured needing preventive and primary care services are obviously straining its fabric.
So-called “safety-net providers” or “community health service providers” that have endeavoured to provide that fabric are changing as well. Federal community health centres (CHCs) and migrant and rural clinics are responding to new incentives, state and local direct delivery organizations are looking to other public health roles, and private voluntary agencies are defining their place in “a civil society.” In some communities, nursing centers are joining CHCs and other public as well as private agencies in addressing safety-net needs. The nursing center, which also may be called a “nurse-managed center,” “nurse-run clinic,” and “community nursing organization,” is one in which a nurse occupies the chief management position, accountability and responsibility for client care and professional practice remain with nursing staff, Nurses are the primary providers seen by clients visiting the center.”
Nursing centers are responding to various factors, such as advanced practice nurses’ drive for an expanded role in health delivery, some managed care plans’ use of advanced practice nurses as primary care providers, and greater discretion under state practice laws for advanced practice nurses to exercise authority.
Schools of nursing, based at academic health centers (AHCs), see nursing centers as sites for health promotion, disease prevention, primary care services, and training. Community activists view them as grass-roots community health care models, partnerships that exist at the invitation of the community and have established community boards. Everyday citizen’s particularly in inner-city and isolated rural areas perceive them as essential sources of preventive and primary services. With the advent of managed care and other health marketplace changes, nursing has put forth its model of providing access to preventive and primary services through nursing centers in schools, community and recreation facilities, public housing projects, homeless and domestic violence centers, strip malls, and other places in urban and rural/frontier areas where people gather. While physicians are involved—to review records, prescribe drugs, and handle referrals, depending upon state nursing practice laws the centers are nurse-operated and nurse-managed. But, just as the old public health nursing model faced funding problems, the nursing center must piece together clinical service, teaching, grant, and other funding in order to establish and maintain it. While the same is true for other safety-net providers, the nursing center faces some particular difficulties.
The relative newness of the reshaped model, the difficulty of moving from subsidized to self-sustaining, and issues surrounding independent practice for nurses are major barriers. This Forum session will delve into the field of advanced practice nursing to examine the nursing center. Centering on the role that advanced practice nursing plays for vulnerable populations in this country’s evolving health marketplace, the meeting will explore the field’s history, goals, inner-city and rural outreach, services, workforce, payment concerns, and educational functions. This session is based in part on two site visits that NHPF hosted to
While nursing centers—in addition to providing comprehensive primary health care—may focus on health promotion and disease promotion services, on the one hand, and on single-purpose functions (such as women’s health) on the other, most are involved in primary care. In 1994, the Institute of Medicine, National Academy of Sciences, defined primary care as the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community,
A PROFILE AND EXAMPLES OF NURSING CENTERS
Although nursing centers may be found in middleclass suburbia and yuppie workplaces, they are most apt to be in sites that serve vulnerable people—the working poor, low-income mothers and children, homeless persons, and others with special needs. The 1998 AACN survey (with 119 nursing-school-associated nursing centers reporting) indicated that most of the centers—63 percent—were in urban areas, with 65 percent in inner-city sites. Only 7 percent were in rural sites. Although about 27 percent were based at the nursing schools themselves, 28 percent were in elementary or secondary schools, 25 percent were at senior or neighborhood centers, 22 percent were in public housing projects, 16 percent were in community centers, 15 percent were in shelters, 15 percent were in student health centers, 9 percent were in churches, 8 percent were in storefronts, 7 percent were in hospitals, 5 percent were in mobile vans, 3 percent were in businesses and other commercial locations, and 24 percent were listed as “other” (some schools had centers at more than one site).
Culturally diverse patients made up 54 percent of the centers’ caseloads, with persons over age 85 comprising 30 percent; non- English speaking, 25 percent; homeless, 19 percent; victims of abuse, 14 percent, people described as substance abusers, 11 percent; mentally ill, 8 percent; HIV-positive, 2 percent; migrants, 6 percent; developmentally disabled or handicapped, 5 percent; pre-term infants, 3 percent; prisoners, 2 percent; other, 21 percent; and none of the above groups, 19 percent (again, there was overlap among the categories)
Potential Uses in Practice
- Staff orientation
- Staff development
- Staff self and external evaluation
- Development and revision of job descriptions
- Evaluation of agency capacity for population-focused public health nursing practice
- Workforce development
- Informing others about nature of public health nursing practice
Potential Uses in Education
- Curriculum guide
- Staff development
- Student self and external evaluation
Future Plans
- Reliability testing
- Research on competency levels of population-focused public health nurses in various settings
Health nursing is a systematic process by which:
The health and health care needs of a population are assessed in order to identify subpopulations, families, and individuals who would benefit from health promotion, or who are at risk of illness, injury, disability or premature death.
· A plan for intervention is developed with the community to meet identified needs that take into account available resources, the range of activities that contribute to health, and the prevention of illness injury, disability, and premature death.
· The plan is implemented effectively, efficiently and equitably.
· Evaluations are conducted to determine the extent to which the intervention has an impact on the health status of individuals and the population.
· The results of the process are used to influence and direct the current delivery of care, deployment of health resources, and the development of local, regional, state, and national health policy, and research to promote health and prevent disease.
This systematic process is based on and is consistent with:
• Community strengths, needs and expectations;
• Current scientific knowledge;
• Available resources;
• Accepted criteria and standards of nursing practice;
• Agency purpose, philosophy and objectives; and
• The participation, cooperation, and understanding of the population.
Other services and organizations in the community are considered, and planning is coordinated to maximize the effective use of resources and enhance outcomes.
The title “public health nurse” designates a nursing professional with educational preparation in public health and nursing science with a primary focus on population-level outcomes. The primary focus of public health nursing is to promote health and prevent disease for entire population groups. This may include assisting and providing care to individual members of the population. It also includes the identification of individuals who may not request care but who have health problems that put themselves and others in the community at risk, such as those with infectious diseases. The focus of public health nursing is not on providing direct care to individuals in community settings. Public health nurses support the provision of direct care through a process of evaluation and assessment of the needs of individuals in the context of their population group. Public health nurses work with other providers of care to plan, develop, and support systems and programs in the community to prevent problems and provide access to care.
Caring-Healing Nursing Practice Model
The Caring-Healing Nursing Practice Model was developed based on the belief that caring and healing are the fundamental principles of the profession of nursing and unique to the care expressed through the practice of nursing. The attributes of compassion, empathy, and altruism are essential to the construct of caring. The components of body, mind, and spirit unite to create the construct of healing. The interconnectedness of these factors in the practice of nursing is reflected in the nurse patient relationship. The intent of the Caring-Healing model is to create a working environment that values these beliefs and results in more holistic patient care and greater nurse/staff satisfaction. The design of this integrative model is based on the belief that caring and healing are irreducible aspects of the practice of nursing. Holistic nursing modalities provide nurses with an additional set of skills-such as massage therapy, guided imagery, and relaxation techniques-to generate a caring-healing environment in which to work and ultimately create a caring-healing encounter that is transforming for nurses and patients.
The authors believed that the introduction of the Caring-Healing Nursing Practice Model could make a difference iursing care at SECC. With the support of the president and CEO of the medical center as well as the vice president for patient care services, a plan to implement this model on a pilot unit was developed.
Implementation of the Caring-Healing Practice Model
The implementation plan included three phases: an information phase, a commitment phase, and an education phase. The first phase included information sessions for the staff on the pilot unit. Small groups of staff from all shifts listened to a 30-minute presentation explaining the concepts of caring and healing and the intended benefits to patients and staff. The presentation stressed that the intention of the model was to reaffirm the fundamental beliefs and values of nursing and offer holistic modalities that would create a supportive environment for nursing practice and enhance patient care. The focus and beneficiaries included the nurse, the nurse and patient, collegial nursing relationships, and the environment of care. At the conclusion of this phase, the staff members were asked their reactions to the Caring-Healing model and if they were willing to participate in the pilot project.
Once the staff agreed to pilot the model, the second phase was initiated. The staff was assisted in creating a mission statement and goals for the unit that reflected the beliefs and values of the model. Again, small group sessions were scheduled with staff. They brainstormed ideas for the mission and goals. Once all ideas were generated, the staff members were asked to identify those statements that were congruent with their own beliefs about nursing and nursing practice and whether these ideas were consistent with how they wanted to practice on the unit. Poster sheets of paper filled with ideas lined the nursing conference room walls. Staff members were told they could add to, support, or question any of the statements. A mission statement and goals were written from these ideas and circulated among the staff for approval. The staff understood that approval meant commitment to these ideals. The final statement of mission and goals were approved and posted in the unit.
The educational phase was initiated once the mission and goals were accepted. Educational sessions to teach the staff holistic nursing modalities were scheduled. All staff was taught techniques of progressive relaxation, guided imagery, therapeutic suggestion, and hand massage. Theoretical background regarding the efficacy of the techniques was discussed, demonstration of the techniques was provided, and opportunity for practice was given.
In the education session, the staffs were asked to identify techniques they felt would be easy for them to initiate with patients. The staff could readily identify their comfort level with the specific modality and easily name patients with whom these modalities would be helpful. In addition, the staff chose one modality they would commit to using at the change of shift. The rationale was that each work shift would have a distinct symbol of caring-healing for each other and the patients as well as setting the intention for caring-healing at the beginning and end of each shift. Following the educational sessions, faculty, graduate students, and staff were available for follow-up support on the unit with individual staff.
Evaluation of the Caring-Healing Nursing Practice Model
Specific criteria were evaluated prior to the implementation of the Caring-Healing model. The Instrumental Caring Inventory (Donius, 1995) and the Index of Work Satisfaction (Stamps, 1986) were administered to the staff of the pilot unit to measure attitudes of caring and job satisfaction. The JCAHO Clinical Indicator of Patient Satisfaction and the Human Resource Indicator of Turnover Rates also were measured. Reevaluation of these outcome measures will be taken at six-month intervals for one year.
Although the educational sessions have just been completed, the anecdotal information from the staff is very positive. Perhaps the most interesting finding so far is that nurses and staff members are using the techniques with each other before they use the techniques with patients. Nurses verbalize their oweed for stress-reducing techniques and their ease with integrating the techniques into their personal lives as well as with their colleagues.
In a small group follow-up session, nurses reported a change in atmosphere on the unit. They cited that the tension and hectic pace has been reduced since the implementation of the model. One nurse said, “I came to work on my day off because I like working here now.” In an education session, the staff identified a co-worker who was especially stressed and discussed how they could offer her the modalities to reduce her stress. Instead of being annoyed by the staff member’s short temper, the nurses were noting how they could help her.
The staff on the day shift is using a variation of guided imagery and prayer to begin their workday. Evening and night shifts are trying to integrate progressive relaxation into their change of shift routines. Although the techniques are easily acquired, the consistent use needs to be reinforced with guidance and support.
Case management
The Nurse Case Manager works to ensure that quality health care is being delivered in an efficient, cost-effective manner to individual patients as they move from setting to setting within the health care system. A Nurse Case Manager usually specializes in the delivery of care to a specific population, such as adults, families, children, the elderly, AIDS patients, patients with cardiovascular disease, etc.
Case management is a care delivery model designed to coordinate and manage patient care across the continuum of health care systems. Case managers are usually involved over an “entire episode of illness/ disability or need for services”. Numerous definitions of case management often relate specifically to the profession, the organization, or the client group. The
Nursing case management is a dynamic and systematic collaborative approach to provide and coordinate health care services to a defined population. The framework includes five components: assessment, planning, implementation, evaluation, and interaction.
Nurse case managers actively participate with their clients to identify and facilitate options and services for meeting individuals’ health needs, with the goal of decreasing fragmentation and duplication of care, and enhancing quality, cost-effective clinical outcomes.
Although its roots are over a century old, contemporary case management began in the 1970s as a way to assure both quality outcomes and cost containment in an increasingly complex system. At that time, a variety of factors had converged to cause inflation in health care. Traditional indemnity insurance plans and federally funded programs had few incentives to control costs. Advances in technology were becoming prohibitively expensive. The aging population and an increase in incidence of chronic illness placed additional burdens on the health care system. Duplication and gaps in services were becoming more frequent. The uncontrolled growth of health care costs led to the emergence of “external” case management, as insurance companies and other third-party payers sought effective means of controlling expenses, especially those associated with catastrophic illnesses and injuries. A decade later, acute care facilities began to feel the impact of decreasing revenues. Hospital restructuring efforts strove to standardize plans of care and reduce costs, while improving quality; thus, “internal” case management was developed. Today, case managers can be found worldwide, in acute care, rehabilitation and subacute facilities, community-based programs, home care, and insurance companies.
The practice of case management depends a great deal on the type and structure of the organization. Although case managers can arise from many disciplines, most have a background iursing or social work. Nurses are well suited to the role because the functions of case management closely follow the framework of the nursing process: assessment, planning, implementation, and evaluation. Case management as a process broadens this framework and incorporates additional components, such as patient identification or case selection; resource identification; advocacy; coordination, monitoring, and evaluation of care; data collection and analysis; and documentation of multiple outcomes, including cost, quality, and client status.
Due to its inherently collaborative and multidisciplinary nature, the process of case management involves the client, family, and other members of the health care team. Coordination of care fosters the efficient use of resources. However, even in the era of managed care, cost-control, while essential, is not the only goal. Quality of care, continuity, and assurance of appropriate and timely interventions are also crucial. In addition to reducing the cost of health care, case management “has proven its worth in terms of improving rehabilitation, improving quality of life, increasing client satisfaction and compliance promoting client self-determination”.
Case management today
The practice of case management is evolving and, to a large degree, still depends on the setting. Historically, preparation for the nurse case manager occurred in the health care organization and was specific to the role, responsibilities, and scope of practice in the institution. More recently, preparation for nurse case managers has been embraced in the academic setting. Baccalaureate education is seen as minimal preparation, and preparation at the graduate level as advanced practice nurses is increasingly emphasized. Competencies achieved at the graduate level correspond with the complex role and responsibilities of the nurse case manager. Regardless of academic preparation, to be effective, the nurse case manager must possess clinical expertise, effective communication and problem-solving skills, and broad knowledge of the health care system, including financing, regulations, and resources.
The American Nurses Credentialing Center offers an exam-based nursing case manager certification for registered nurses with demonstrated clinical experience in case management <http://nursingworld.org/ancc/>
The
The literature of such a discipline is by nature multidisciplinary, with an emphasis on journals addressing the clinical specialization of the case manager as well as those focusing on case management methodology and the health care system. For purposes of this evaluation, the authors focused on literature covering the process, methods, and expertise required by case managers regardless of setting or clinical specialty.
This study is part of a larger project sponsored by the Nursing and Allied Health Resources Section of the Medical Library Association to map the literature of nursing. The purpose of this mapping project is to add to the knowledge of the nursing literature by identifying the core literature of the various disciplines through citation analysis. Citation analysis can assist librarians with collection development decisions and strengthen librarians’ knowledge of the breadth of the literature for a specific discipline. In addition, this project attempts to determine the extent of indexing coverage for the core literature. Identifying and determining indexing coverage of the core literature should also assist case management students, faculty, and practitioners in accessing the key literature for research and practice.
MEthodology
The common methodology is described in detail in the project overview article. A review of the literature revealed no bibliographic studies relating to case management. In addition, case management journals were not featured on standard bibliographies or core lists, such as the Brandon/Hill list. Many serials related to case management were clinically oriented or were trade publications or newsletters. To determine source journals for this study, the authors reviewed Key and Electronic Nursing Journals: Characteristics and Database Coverage, the literature of professional case management organizations, and the holdings of major academic medical libraries.
Only three journals met the authors’ criteria for inclusion: professional, peer-reviewed journals that were routinely held by academic health sciences libraries and contained at least some research articles:
- The Journal of Care Management (JCM) is the official journal of the Case Management Society of America. In 2000, the journal was renamed CareManagement: Official Journal of the
Academy ofCertified Case Managers - Nursing Case Management (NCM) was, when this study began, the only case management journal specifically targeted for professional nurse case managers. The title change to Lippincott’s Case Management in 2000 reflects the multidisciplinary nature of case management practice, while the published articles still primarily reflect nursing practice. NCM publishes articles related to both the clinical and management aspects of case management and includes opportunities to attain continuing education credit.
- The Journal of Case Management (TJCM) is the third journal specific to the field of case management. Its multidisciplinary articles relate to both nursing and social work. In 1999, this journal merged with The Journal of Long Term Care to become The Care Management Journals. The two journals are published as separate titles under one cover. Connecting the two journals emphasizes continuity of care, while allowing each to retain its specialty focus. For purposes of this study, only titles published under TJCM were evaluated.
The three selected journals cover the broad spectrum of nursing case management practice. That each journal has undergone a change in title, focus, or format reflects the continuing evolution of case management as a discipline.
The field of case management has been developing rapidly, with its significance increasing over the past two decades. Secondary sources such as books and monographs constituted a significant portion of the cited literature, especially for articles discussing the process of case management. More than 67% of the books from the 1990s were published prior to 1997, while 26% of the total books were published in the 1980s. Because 33% of the source articles were published in
Other nontraditional formats, such as government documents and the reports of professional organizations and advocacy or advisory groups were also important components of the core literature. Although more than 86% of the government documents were from the 1990s, more than 50% of those were published in the early portion of the decade. Again, this reliance on older literature might be the result of using what was convenient. Access to and knowledge of the plethora of government statistics, guidelines, and other documents via the Internet should improve the currency of the reference literature.
Current statistics and disease information were frequently derived from associations’ or nonprofit organizations’ publications and Websites, listed under reports. The reports were more current than other categories. Citing recent conferences and drug inserts might also slant the miscellaneous category toward currency. As knowledge of, and comfort with, accessing quality information via the Internet improves; it will be interesting to track the number of future citations in the Internet category. Will there be increased reliance on general Websites and online communication or will the online version of traditional reports be cited? If the latter occurs, will it impact the currency of those citations?
The diversity of cited journals reflects the dual focus of nursing case management—managing the patient while also managing the process of patient care. Judging from the source articles and the titles of the cited journals, the literature of case management can be divided into two broad categories: literature related to the process of case management and the health care system and “clinical” literature. One possible explanation for the emphasis on process is that case management practice is relatively new and needs to be defined along with its role in both the health care and educational systems. Many case managers have learned case management from peers, have heavy caseloads, and frequently work independently Journals permit nurse case managers to remain current on contract theory, delivery models, case maps, discharge planning, communication, legislation, and economics.
Given this diversity, one challenge for nurse case managers is to determine which databases to select when searching for pertinent articles. As the indexing coverage demonstrated, PubMed provides good coverage, especially when the focus of the search is on the clinical aspects of practice. Given the multidisciplinary nature of case management, one might have expected greater coverage in those databases with a social sciences focus. Indexing scores for “social work” titles generally are higher in these databases. Of the two nursing databases, CINAHL provides better coverage. Most, but not all, of the nursing journals are extensively indexed. OCLC ArticleFirst should not be overlooked; more than 87% of the journals in Zones 1 and 2 are indexed. Although case management titles are generally not indexed, the coverage for social sciences is very strong, thus potentially complementing the coverage in the more clinically focused databases. However, PubMed/MEDLINE remains the database of choice when searching for information related to case management. In addition to its excellent coverage, it is both free of charge and readily available.
The appearance of journals specific to nursing research and advanced practice nursing in Zones 1 and 2 may reflect the shift toward post baccalaureate preparation for nurse case managers. Theories and instruments are beginning to emerge in case management and nurse case managers with advanced degrees would be expected to have better knowledge of analyzing and performing research. As a result, it could also be expected that literature reviews would be more thorough and current and that reliance on the older but easily available textbooks should lessen.
The core literature also reflects a growing mandate for nurse case managers to manage complex patient populations, which requires sophisticated knowledge of specialty practice. Many of the articles in the source journals discuss the management of specific patient population specialities, such as gerontology, psychiatry, oncology, or neurology. For instance, articles might discuss the latest treatments and trends in wound care, pain control, infectious diseases, or even multicultural communication styles. The focus on providing continuing education credit in two of the source journals (JCM and NCM) may encourage nurse case managers to remain current. These articles frequently reference current materials and provide an alternative to those with limited access to, or knowledge of, libraries and bibliographic databases.
As of early 2005, case management is being discussed in a broader range of journals and trade publications than previously noted in the 1997-to-1999 examination, which may indicate the acceptance of and need for this process-and-outcomes model across the disciplines. However, the three core journals identified in this study remain the only core case management journals and thus an essential part of any collection that supports case management practice. While not part of this study, several of the newer case management newsletters appear robust and may be useful to several library collections. Furthermore, it will be interesting to keep track of new journals focused on geographic areas, such as
A comprehensive journal collection for nurse case managers would include titles specific to case management, journals addressing heath care and nursing administration issues, and key journals in their clinical specialty areas. Librarians have the opportunity to play an important role in educating nurse case managers about current sources of information and access to information via alternative platforms, such as the Internet. In some instances, librarians might participate in the case management team by providing timely access to current information through literature searches and document delivery.
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Case Management is the process of organizing and coordinating resources and services in response to individual healthcare needs along the illness and care continuum and in multiple settings. There are many models for case management given client, context, or setting. Case management is directed toward a targeted or selected client/family population such as transplant, head-injured, or frail elderly clients. The goals are to center services around the patient, to foster patient self-managed care, and maximize efficient and cost-effective use of health resources. The focuses are cost-saving and continuity and quality of patient care. The Nurse Case Manager utilizes clinical pathways in assessment and monitoring of clients and healthcare delivery |
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Settings: |
Varied hospital-based and community-based settings including occupational health |
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Characteristics: |
Coordination of care and services, case finding, screening, eligibility, determination; comprehensive assessment; development, monitoring, and evaluation of the plan of care and use of resources and arrangement of services to reach outcomes in specific time frames |
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Drawbacks: |
Honoring client choices, minimizing time constraints, maintaining a holistic focus, linking care-team members, and impacting quality and cost |
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Desirable skills: |
Strong knowledge base in financial and clinical aspects of care, working knowledge of resources, and effective skills in managing, teaching, negotiating, and collaborating with multidisciplinary groups, and client/family focus |
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Education: |
RN with BSN or MSN (preferred) |
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Employers: |
Hospitals, community agencies, third-party payers |
Case management models
· . Dimensions of Nursing Case Management
· Two Strategies for Managing Care: Care Management and Case Management
· Disease Management: Applying Systems Thinking to Quality Patient Care Delivery
Case Management oftentimes includes
· Preventing unnecessary or repetitive medical care (Disease Management)
· Evaluating your ability to remain safe and independent in the residence
· Obtaining proper medical care and securing necessary medical supplies and equipment
· Obtaining home care nursing services
· Obtaining assistance with homemaking and personal care needs
· Coordinating service delivery and necessary medical follow-up
· Providing information and education about community resources and residential options
Four Key Functions of Case Management –
- Assessor
- Planner
- Facilitator
- Advocate
Summary
Case management was found to have a primarily positive effect ourses-staff and case managers alike. There were significant increases in several aspects of the nurses’ perceptions of the quality of care delivered. Additionally, case managers were more satisfied with the administration, the respect they received, and their pay and rewards in the institution. Most strikingly, case managers perceived themselves to have more control over their practice. Some negative effects of the program were a decrease in satisfaction with the pay and rewards by the staff who were not case managers.
References
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· 4. Patricia Gerrity and Katherine K. Kinsey, “An Urban
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Interner resources
· Centers for Disease Control & Prevention (CDC) http://www.cdc.gov/
· Missouri Department of Health and Senior Services (DHSS) http://www.dhss.mo.gov/
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· http://www.ded.mo.gov/regulatorylicensing/professionalregistration
· National Association of Local Boards of Health (NALBOH) http://www.nalboh.org/
· National Association of City County Health Officers (NACCHO) http://www.naccho.org/
· American Public Health Association (APHA) http://www.apha.org/
· Association of State & Territorial Health Officers (ASTHO) http://www.astho.org/
· Missouri Association of Local Public Health Agencies (MoALPHA) http://www.moalpha.org/
· Missouri Institute of Community Health (
· Missouri Public Health Association (MPHA http://www.mopha.org/
Evaluation Tools
· Guide to Community Preventive Services http://www.thecommunityguide.org
· Health Insurance Portability and Accountability Act of 1996 (HIPAA)
· Missouri Voluntary Local Public Health Agency Accreditation Program
· http://www.michweb.org/accredoverview.html
· National Public Health Performance Standards Program http://www.phppo.cdc.gov/nphpsp
