Community
Based Nursing. Perspectives in Health Care Delivery.
Influences
on Health Care Delivery and Community Health Nursing
After studying this chapter,
you should be able to:
- Connect
the historical development of community health nursing to present-day
issues.
- Describe
factors influencing community health nursing in the 21st century.
- Explore
the theoretical underpinnings of community health nursing practice.
- Analyze
the nurse's role in promoting health.
Introduction
The 21st century is bustling
with phenomenal opportunities and challenges for health care delivery and
community health nursing. There is no better time to be a community health
nurse. The discussion that follows represents some reflections on what we
believe will characterize the practice of community health nursing in the 21st
century. We use the term community health nursing to denote the practice of
nursing by professional nurses who have been educated in the processes of
population-based nursing and whose principal client is the aggregate community.
In the past, population-based
nursing was referred to as public health nursing. Public health nurses usually
worked in health departments. This text uses the term community
health nurse, which was adopted in recent years and intended to be more
inclusive of population-based nursing practiced in a variety of community
settings, including schools, worksites, shelters, health departments, and a
multitude of others, some of which will be discussed in Part 3 of this text.
You will encounter both terms, public health nursing and community health
nursing, during your education and practice. Titles and practice settings are
not as relevant as the nature of the practice itself. This chapter discusses
the essence and diversity of that practice along with its theoretical
underpinnings.
Until now the majority of your
nursing education has focused on individual behavior.
The theoretical basis for your nursing care has included knowledge about
chemistry, physiology, pharmacology, and so on. Community health nursing, too,
relies on that basic knowledge, but is also based on theories about
populations. Hence, you will discover in subsequent chapters the concepts of
epidemiology, demography, ethics, environment, culture, and policy. To
understand why these theories are important to the community health nurse,
let's begin with a bit of historical context.
Reflections on the Past
As we move forward into the
21st century, reflecting on the historical contributions of community health
nurses is both instructive and inspirational. Examining our roots allows us to
take the best from the past in order to shape the future. Community health
nurses can gain motivation and direction from the work of Lillian Wald, Lavinia Dock, and Margaret
Sanger who “make up nursing's
‘distinguished history of concern…for social justice’†(Bekemeier & Butterfield, 2005, p. 153) and who, more
than 100 years ago, “…grew
indignant from witnessing the destructive health outcomes of institutionalized
poverty and of gender and ethnic inequalities†(Bekemeier &
Butterfield, 2005, p. 153). Observing rapid industrialization, large
concentrations of people moving into cities, unsanitary environmental
conditions, poor housing, poverty, misuse of child labor,
infectious diseases, and short life expectancy, Lillian Wald
and Mary Brewster were moved to action. Together, they founded the Henry Street
Settlement House in
With the discovery of
antibiotics in the 1940s and vaccines for mass immunizations in conjunction
with tremendous improvements in environmental sanitation, the
Beginning in the 1960s, as
communicable diseases declined, attention turned to prevention of chronic
diseases and related risk factors such as cigarette smoking and dietary fat.
Community health nurses working in health departments focused attention on
screening, case finding, home visiting to individual clients, and health
education activities related to disease prevention. This trend continued into
the early 1980s when the focus of health shifted somewhat to health promotion,
prompted by the Health for All era established by the World Health Organization
(WHO, 1978). However, the 1990s were marked by considerable emphasis on
clinical care and high-tech medicine as ways to increase life span in the
Ten Great Public
Health Achievements in the 20th Century
|
2.
Improvements in motor vehicle
safety 3.
Workplace safety 4.
Control of infectious diseases 5. Decline in deaths from heart
disease and stroke 6.
Safer and healthier foods 7.
Healthier mothers and babies
8.
Family planning 9.
Fluoridation of drinking water
10. Recognition of tobacco as a
health hazard |
|
Centers
for Disease Control and Prevention. (1999). Ten great public achievements— |
In recent years, official
agencies have become more involved in direct clinical care, and community
health nursing has focused on clinical and illness care or “clinic†roles and functions,
assigning less importance to family- and community-focused roles and functions.
This shift was primarily in response to the reimbursability
of clinical services. Now public health is shifting back to its “roots†and is focusing more on
disease prevention, health promotion, and assurance that care is provided,
rather than providing one-on-one care. To respond to the challenges facing
community health nursing in the future, we must understand the changes
occurring in health care delivery, including directions for population-based
health.
In recent years, official
agencies have become more involved in direct clinical care, and community
health nursing has focused on clinical and illness care or “clinic†roles and functions,
assigning less importance to family- and community-focused roles and functions.
This shift was primarily in response to the reimbursability
of clinical services. Now public health is shifting back to its “roots†and is focusing more on
disease prevention, health promotion, and assurance that care is provided,
rather than providing one-on-one care. To respond to the challenges facing
community health nursing in the future, we must understand the changes
occurring in health care delivery, including directions for population-based
health.
Community Health in the
Past debates about health care reform largely ignored
the contributions of population-based community health, concentrating almost
entirely on clinical care, with the exception of immunizations. Mechanisms to
deliver and pay for illness care are driving current health care system
changes. The debate really ought to be about what can be done to make our
population the healthiest rather than how we can best pay for illness. Some
elected officials have been reluctant to fund health promotion services at the
levels needed, but it takes excellent health promotion to minimize the cost of
illness care. Health promotion results in wellness. Community health in the
21st century must offer integrated services and activities that focus on
minimizing threats to health, promoting wellness, and then focusing on illness
management. This fact will become more apparent as managed care organizations
gain more experience and realize that the key to their profits is investment in
health promotion services. These managed care organizations are already turning
more dollars toward health education and wellness activities of members.
Clearly, to advance community health nursing, a focus
on the core functions of public health (Institute of Medicine, 1988) and the
ten essential public health services (Association of State and Territorial
Directors of Nursing, 2000) is imperative. The three core functions include 1)
regular and systematic community assessment; 2) policy development; and 3)
assurance that necessary services will be provided. The ten essential public
health services can be used as a guide to ensure comprehensive community health
nursing practice. These essential services are listed in Table 1-1 and are
accompanied by selected nursing activities as examples of each service. These
essential services comprise an impressive list, and each service can be used to
direct community health nursing practice in a diversity of settings.
In addition, a term that is discussed frequently is
outcomes management. Professionals are queried as to what measures they can
offer to document improvements in health and well-being. Outcomes measures are
being used to determine operating budgets in a number of institutions. Outcomes
management is in the future of community health and, consequently, community
health nursing.
|
Table
1-1 Essential Public Health Services and Selected Nursing Activities |
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Community Health
Nursing Practice
To describe community health
nursing more clearly, a group of four nursing organizations met (Quad Council
of Public Health Nursing Organizations, 1999). The four organizations were
called The Quad Council and consisted of the American Nurses Association,
Council of Community, Primary, and Long-Term Care; American Public Health
Association—Public Health Nursing
Section; Association of Community Health Nurse Educators; and Association of
State and Territorial Directors of Nursing. Their definition of the scope of
public health nursing practice is quoted below:
Public health nursing is the
practice of promoting and protecting the health of populations using knowledge
from nursing, social, and public health sciences (American Public Health
Association, Public Health Nursing Section 1996). Public health nursing is a
population-based, community-oriented nursing practice. The goal of public
health nursing is the prevention of disease and disability for all people
through the creation of conditions in which people can be healthy.
Public health nurses most
often partner with nations, states, communities, organizations, and groups,
along with individuals, in completing health assessment, policy development,
and assurance activities. Public health nurses practice in both public and
private agencies. Some public health nurses may have responsibility for the
health of a geographic or enrolled population, such as those covered by a
health department or capitated health system, whereas
others may promote the health of a specific population, for example, those with
HIV/AIDS.
Public health nurses assess
the needs and strengths of the population, design interventions to mobilize
resources for action, and promote equal opportunity for health. Strong,
effective organizational and political skills must complement their nursing and
public health expertise (Quad Council of Public Health Nursing Organizations,
1999, p. 2).
In addition, The Quad Council
explicated the eight tenets of public health (community health) nursing
practice to advance the goal of promoting and protecting the health of the
population (
The Eight Tenets of
Public Health (Community Health) Nursing
Factors Influencing Community
Health Nursing in the 21st Century
All health professions are
being influenced by the changes occurring in our health care system. Some
relevant factors shaping 21st century community health are summarized in
Health Care Delivery
System
population focused. The present focus of
change in health care delivery centers on cost
containment. Competition based on market forces is a major driver in the
emerging health care system. Managed care has taken over nearly all aspects of
individual and family care, including government-sponsored programs. Large,
integrated health systems are rapidly developing with mergers of large
hospitals, physician practice groups, nursing home care facilities, home health
agencies, and other specialty All aspects of health
care are becoming increasingly community based and groups. All of these factors
create the challenge of balancing the needs of the individual within the
broader social context. The increase in managed care organizations has meant
fewer individual patients for health departments (and less revenue) in
prenatal, well-child, and family planning clinics. This change means that the
Medicaid population is cared for by managed care groups and there is less need
for health department clinical services.
One innovative program aimed
at our fragmented system serves as an example of how health professionals can
partner to affect the health of our citizens. This program, Turning
Point, was begun in 1997 with funding from the Robert Wood Johnson Foundation
and additional funding from the W. K. Kellogg Foundation. Citing that threats
to our nation (bioterrorism and emerging infectious diseases, along with
obesity, violence, and tobacco-related illnesses) require a strong public
health system, they also point out, “Half of the world's health care dollars are spent in
the
Factors Shaping 21st
Century Health
|
Health care delivery “system†|
Take Note
The mission
of Turning Point is “to transform and strengthen the public health
system in the
Demographics
Many countries with very large
populations have shown great progress in lowering their birth rates. However,
the very size of their current populations means that, in absolute terms, their
populations will continue to increase for many years. As large numbers of young
people become sexually active, they, in turn, will place greater pressures on
local health services, schools, and employers. In the
Family structures and living
arrangements are also changing rapidly in much of the world. Fewer people live
in traditional family groups or have extended family support networks. The
stress that often results from these changes, along with the growing disruption
of traditional cultural patterns, is another factor adding to the erosion of
social support systems and people's burden of disease.
Two significant demographic
factors shaping the future of community health nursing and all health care are
age and increasing ethnic diversity. Studies predict that by 2040, one out of
five Americans will be 65 years or older. The graying
of
Globalization
The major factor affecting
communities today and in the foreseeable future is the phenomenon known as
globalization. Globalization represents a global market that brings together
capital, technology, and information across borders to create what some call a
global village (Friedman, 1999). When global financial markets go up or down,
when trade agreements are negotiated, when recessions threaten the countries
that purchase the products made in our towns and communities, we and our communities
can be in danger. When recession or political instability occurs in other
countries, foreign companies often lower their prices to make their products
more competitive. They are able to do this and still make a profit because the
levels of local unemployment create conditions in which those competing for
jobs are willing to work for less and less. When this happens over a period of
time and is widespread, companies and factories, once considered sources of
stable employment in our communities, frequently close their
With the growing strength of
organizations such as the World Trade Organization (WTO) and trade pacts such
as the North American Free Trade Agreement (NAFTA) with their emphasis on free
trade, free financial markets, and economic profits, governments—especially those of resource-poor nations—find themselves losing the ability to define
and control their own futures. Political scientists and sociologists warn of
the declining strength of the “nation
state†and the questionable future
of international organizations such as the United Nations (UN) and its related
units such as the World Health Organization (WHO). If many countries are
weakening in relation to powerful international forces, what does this mean for
the development of our local communities? How are they affected by the emphasis
on profit—usually for a few privileged
individuals and companies?
Globalization, however, can have many positive
consequences in our lives. New technologies bring almost instant communication
with other parts of the world. Today, mobile phones, many connected to satellites,bring nearly instant
access to previously remote areas. Cyberspace, with its Internetelectronic
mailing lists and chat rooms, allows us to learn of other people's realities—their dreams, needs, and challenges. How can
these same advances in technology and information be used by communities in
their struggles for social justice and equity for all?
Poverty and Growing
Disparities
Although it is true that many
of us have improved our standard of living, nearly half the world's population
still lives on less than $2 per day, and approximately 1.2 billion people must
live on less than $1 per day (United Nations General Assembly, 2000). People's
health and well-being suffer the most when they are unable to secure
appropriate employment and can no longer access adequate “social safety nets†and supportive services.
Take Note
“Health disparities are
differences in the incidence, prevalence, mortality, and burden of diseases and
other adverse health conditions that exist among specific population groups in
the United Statesâ€
(National Institutes of Health, 2006, p. 1).
Wherever people live, poverty
has been identified as a major cause of malnutrition and illness, thus
undermining the efforts of health workers and health services. Whether at home or at work, the poor are often more exposed to
pollution and other health risks than others. They frequently eat
poorly, whether in quantity or in quality, and are more likely to smoke tobacco
and be exposed to other harmful substances. Differences such as these are found
throughout the world, including in the
But poverty is not the only
disparity. Additional disparities identified are geographic and racial or
ethnic. Lack of health insurance is a major disparity as we see in the
following: “Despite Medicaid expansions
during the past decade and implementation of the State Children's Health
Insurance Program (S-CHIP) in 1997, there are more than 9 million uninsured
children in the United States†(Frist, W. H., 2005, p. 270).
Devoting entire issues of
nursing journals to the topic reflects the importance of health disparities in
the
Primary Health Care
After extensive preparation,
delegates from 134 nations of the world, plus representatives from
non-governmental organizations (NGOs) officially accredited by WHO, met during
September
At Alma Ata, the original WHO
definition of health was revised on the basis of a newer understanding of
health and its many component parts. According to WHO, health was now to be
defined as “a state of complete physical,
mental, and social wellbeing, and not merely the absence of disease or
infirmity … a fundamental right†(Pan American Health
Organization, 2003, p. 1). As determined at Alma Ata, the principal means by
which this level of health can be realized is primary health care, which was
defined as essential health care; based on practical, scientifically sound, and
socially acceptable methods and technology; universally accessible to all in
the community through their full participation; at an affordable cost; and
geared toward self-reliance and self-determination (WHO, 1978).
Many of the concepts basic to
primary health care are familiar to community health practitioners: prevention,
universal coverage and accessibility, affordability, teamwork, priority setting
to address local problems, effective management, community participation, and
cultural sensitivity. Primary health care shifts the emphasis of health care to
the people themselves and their needs, reinforcing and strengthening their
capacity to shape their own lives. Although hospitals and health centers will always be extremely important to people in
their search for healthier lives, primary health care is based on the principle
that health begins where people live and work (i.e., in their homes, schools,
communities, and places of employment). Understood in its totality, primary
health care becomes not only a level of care but a philosophy and a strategy as
well.
The eight elements essential
to the primary health care approach reflect the priorities identified in 1978
at Alma Ata (
Eight Essential
Elements of Primary Health Care
The shifting emphasis away
from dependence on health professionals and toward personal involvement, along
with the need for more than improved health and medical services, was
underscored in 1997 at a WHO-sponsored meeting in Jakarta when “enabling people to increase
control over and improve their health†through health promotion was included in the Preamble
of the Jakarta Declaration (World Health Organization, 1997, p. 1). Also
included was the affirmation of the prerequisites for health. These
prerequisites were listed as peace, shelter, education, social security, social
relations, food, income, the empowerment of women, a stable ecosystem,
sustainable resource use, social justice, respect for human rights, and equity.
Above all, the Declaration stated, “poverty is the greatest threat to health†(World Health Organization,
1997, p. 1).
More and more nurses work
outside of hospitals in public and community health, expanding their roles well
beyond the bedside. As Bekemeier and Butterfield
(2005) assert, “This is
good news, because research is providing evidence that what is needed to
improve broad health outcomes will be achieved by acting on environments and
inequitable social systems†(p.
154). These two areas are at the heart of primary health care.
Take Note
“Health is … a resource for everyday life, not the
objective of living. Health is a positive concept emphasizing social and
personal resources, as well as physical capacities†(WHO, 1986, p. 1).
Violence, Injuries,
and Social Disintegration
Violence takes many forms and
ranges from highly visible armed conflict and teen street gangs, to the 4
million women and girls sold into sexual slavery each year, to the estimated
25% to 30% of all women who experience domestic violence, and to the 130
million women who are victims of genital mutilation. Entertainment media have
long been able to produce extremely violent movie scenes and games in which the
aim is to kill. In the United States, powerful groups have made easy access to
guns a “right.†Although it is very difficult
to establish a cause-and-effect relationship between the number of guns
available, the violence of the entertainment media, and the number of
gun-related crimes committed by younger and younger people, communities have
become increasingly concerned about violence. They are also concerned about the
weakening of human relationships—in families, between generations, and in communities—that often result in social disintegration.
Internationally, the UN
Convention on the Elimination of all Forms of Discrimination against Women (CEDAW)
was created in 1979 as an important tool for all those who seek to end abuse of
women and girls. The American Nurses Association is one of
some 168 professional, religious, civic, and community organizations that
support ratification of this International Bill of Rights for Women (Working
Group on Ratification, Fact Sheet, 2002). Being aware of such documents and
promoting their adoption is a way the community health nurse can serve as an
advocate.
Take Note
“Health is a social, economic
and political issue and, above all, a fundamental right. Inequality, poverty,
exploitation, violence, and injustice are at the root of ill health and the
death of poor and marginalized people†(People's Health Movement, 2003, p. 5).
Bioterrorism
Terrorist attacks that
occurred in the
Challenges for the Future
Community health nurses in the
future need to stretch themselves and go far beyond traditional nursing
practice in conventional medical and health services. They will continue to be
teachers, advocates, monitors, catalysts, and enablers. They will be
scientifically and technically skilled. They will be knowledgeable about
economics, politics, and global issues. But, most of all, they will be partners
with communities at local, regional, national, and international levels. Amelia
Maglacas, Chief Nurse Scientist of the WHO,
admonished us when she pointed out that enabling people to
increase control over and to improve their health will continue to be an
integral part of all nurses' roles. This new partnership, involving nurses,
communities, and their environments, involves a common search, based on
personal choice and social responsibility, for a healthier future (Maglacas, 1988). Almost 20 years later, her words ring true
for community health nurses.
Summary
This opening chapter has
provided you with an overview of the role of the community health nurse and
introduced you to population-based theories that underpin that role. These
theories will be further elaborated in subsequent chapters. Awareness of the
global factors that affect health and of the essentials of community health
nursing will arm you with the tools and knowledge to work toward improving
health in communities everywhere.
Perspectives in Health Care Delivery
After studying this chapter,
you should be able to:
·
Describe trends in the United States that are
affecting Health Care
·
Identify levels of economic theories
·
Analyze the major components of health care
reforms
·
Identify the factors influencing health care
economics
·
Trace the role of government and other payers in
health care financing
Introduction
A health care delivery system is a mechanism for providing services that meet the
health-related needs of individuals. The
Health Economics lies at the interface
of economics and medicine and applies
the discipline of economics to the topic of health.
Why is it important to look at economics in
health? There are several reasons. Health
resources are finite. A choice must be made about which resources to use for which activities.
By choosing to use resources for one
activity, the opportunity
of using those resources for alternative
activities is given up and the benefits associated with the
best alternative use of resources is lost. This is called the opportunity cost .Let's look at opportunity cost. The aim of economics
is to ensure that the chosen activities
have benefits which outweigh
their opportunity costs OR the most
beneficial activities are chosen within the resources available.
Economics is concerned with efficiency but it is more than just
efficiency. Efficiency is not the only objective in choosing how health care
resources should be allocated. We also need to think about equity, or the fair distribution of
resources and benefits, which is also an objective in health care decision-making. Economics provides an information framework in which the objectives of both efficiency
and equity may be pursued. Economics also provides a framework which aims at maximizing
benefits within available resources.
Health economics depends
on large amounts of data in the following areas for credibility:
·
health care financing
·
cost of care
·
demographic
·
epidemiological
·
socioeconomic
·
economic burden of disease (cost of illness)
·
comparative
Availability and sources of
statistical data will be influenced by the type of health care system in place
Availability and sources of
statistical data may vary between regions within countries
An additional 24% of our population in the same year
was covered by some type of government
plan. The breakdown is as follows: Medicare, 13%; Medicaid,
10%, Military Health Insurance,
3%.
Types of health
care services
Basically,
health care services can be categorized into three levels: primary, secondary,
and tertiary. The complexity of care varies according to the individual’s need,
provider’s expertise, and delivery setting.
Primary:
Health Promotion and Illness Prevention
The major purposes
of health care are to promote wellness and prevent illness or disability.
Traditionally, the
Secondary: Diagnosis and Treatment
Most services
occur within this secondary type of health care. Acute treatment centers (hospitals) are still the predominant site of
delivery of health care services. There
is a growing movement to have diagnostic and therapeutic services provided in
locations that are more easily accessed by individuals. This trend is discussed
later in this chapter.
Tertiary:
Rehabilitation.
Restoring an
individual to the state that existed before the development of an illness is
the purpose of rehabilitative (or restorative) care. In situations in which the
person is unable to regain previous functional abilities, the goal of
rehabilitation is to help the client reach the optimal level of self-care.
Restorative care is holistic, in that the entire person is cared
for—physiological, psychological, social, and spiritual aspects.
Health care settings
The
Public Sector
Public agencies
are financed with tax monies; thus, these agencies are accountable to the
public. The public sector includes official (or governmental) agencies,
voluntary agencies, and nonprofit agencies. Figure
4-2 shows the hierarchy of the public sector of health care delivery. At the local level, services provided include
immunizations, maternal-child care, and activities directed at control of
chronic diseases. Each state varies in the provision of public health services. Generally,
a state department of health coordinates the activities of local health
units. At the
national level, the U.S. Department of Health and Human Services (DHHS) is administratively
responsible for health care services delivered to the public. The Surgeon
General is the chief officer of the U.S. Public Health Service (USPHS), the
major agency that oversees the actual delivery of care services. Table 4-2
lists the USPHS agencies and their purposes.
An important part of the public sector of the health care delivery
system is voluntary agencies. These not-for-profit agencies exert significant
legislative influence (e.g., the American Nurses Association [ANA] and the
American Medical Association). Other voluntary agencies, such as the American
Cancer Society and the American Heart Association, provide educational
resources to the general public and to health care providers. Voluntary
agencies are funded in a variety of ways, including individual contributions,
corporate philanthropy, and membership dues.
Private Sector
The private sector
of the health care delivery system primarily comprises independent providers
who are reimbursed on a fee-for-service basis (the recipient directly
pays the provider for services as they are provided). These practices settings are directly
influenced by social and economic factors.
Economics of health care
The reform
movement in health care has been motivated primarily by health care costs.
Control of costs has shifted from the health care providers to the
insurers. As a result, there are
increasing constraints on reimbursement. For years, the predominant method of
covering health care costs was the fee-for-service method. There was little, if any, incentive for
cost-effective delivery of care (Chamberlain, Chen, Osuna,
& Yamamoto, 1995). All that is changing. The
Private Insurance
The system for
financing health care services in the
Managed Care
Managed care is a system of
providing and monitoring care in which access, cost, and quality are controlled
before or during delivery of services. The goal of managed care is the delivery
of services in the most cost-efficient manner possible. Managed care seeks to
control costs by monitoring delivery of services and restricting access to
expensive procedures and providers.
Managed care was designed to provide coordinated services with an
emphasis on prevention and primary care (ANA, 1995).
The rationale for
managed care is to give consumers preventive services delivered by a primary
care provider (a health care provider whom a client sees first for health
care) that, in turn, results in less expensive interventions. Managed care has been in existence for years;
however, it is only within the past few decades that it has received national
prominence (Society for Ambulatory Care Professionals, 1994). The Health
Maintenance Organization Act (passed in 1973) implemented two mandates.
First, federal
grants and loans were made available to health
maintenance organizations (HMOs) (prepaid health plans that provide primary
health care services for a preset fee
and focus on cost-effective treatment
measures) that complied with strict federal regulations as opposed to the less restrictive state
requirements. Second, the act required
large employers to provide an HMO as an option for employees for health care
coverage (Society for Ambulatory Care Professionals, 1994). From their
inception, HMOs have been a viable alternative to the
traditional fee-for-service system. Managed care is not a place but rather an
organizational structure with a few variations. One is represented by HMOs, which are both providers and insurers.
Other variations are represented by preferred
provider organizations (PPOs) (a type of managed
care model in which member choice is limited to providers within the system)
and exclusive provider organizations (EPOs)
(organizations in which care must be delivered by the plan for clients to
receive reimbursement). The latter creates a network of providers (such as
physicians and hospitals) and offers the incentive of consumer services with
little or no copayment if these providers are used
exclusively. Table 4-6 provides a comparison of independent practice and
managed care organizational structures.
The impact of managed care is that caregivers and institutions must change from providing as
many services as possible under a
fee-for-service payment approach to
keeping the client well and providing fewer
services so as to protect their financial interests. “In a fee-for-service system, the concern is that a
client might receive too many or
unnecessary services; in a prepaid
system, the concern is that too few services might be given in order to save the provider and the
managed care plan money” (Hitchcock,
Schubert, & Thomas, 1999, p. 46).
Health
Maintenance Organizations
The HMOs often maintain primary health care sites and commonly
employ provider professionals. They use capitated
rates (a preset flat fee that is based on membership in, not services
provided by, the HMO), assume the risk of clients who are heavy users, and
exert control on the use of services. HMOs have been
noted for their use of advanced practice registered nurses (APRNs)
as primary care providers, precertification programs
to limit unnecessary hospitalization, and an emphasis on client education for
health promotion and self-care.
Another common
feature of HMOs is the practice of single point of
entry (entry into the health care system is required through a point
designated by the plan) through which primary care is delivered.
Primary health
care is the client’s point of entry into the health care system and includes
assessment, diagnosis, and treatment, coordination of care, education,
preventive services, and surveillance. It consists of the spectrum of services
provided by a family practitioner (nurse or physician) in an ambulatory
setting. Primary care providers (PCPs) serve as “gatekeepers” to the health
care system in that they determine which, if any, referrals to specialists are
needed by the client. To reduce costs, direct access to specialists is
limited. Extensive data collection
proves that APRNs are exceptionally suited to these
primary provider/gatekeeper roles (ANA, 1993a). Managed care plans assume a
significant portion of the risk of providing health care and, consequently,
encourage both prudent use by consumers and prescription by providers.
Preferred
Provider Organizations
The most common
managed care systems are preferred provider organizations (PPOs).
A PPO is a contractual relationship between hospitals, providers, employers,
and third-party payers to form a network in which providers negotiate with
group purchasers to provide health services for a defined population at a
predetermined price (Society for Ambulatory Care Professionals, 1994). Even
though PPOs have been very popular with the American
public, it appears that HMOs are gaining in market
share among the American public (Kelly & Joel, 1995). Currently, managed
care is emerging as the preferred model for delivery of services.
Medicare
Medicare is a social
insurance program administered by the United States government, providing health
insurance coverage to people who are aged 65 and over, or who meet
other special criteria. It was originally signed into law on July 30,
1965, by President Lyndon B.
Johnson as amendments to Social Security
legislation. At the bill-signing ceremony President Johnson enrolled former
President Harry S. Truman as the first Medicare
beneficiary and presented him with the first Medicare card.
When Medicare was
established in 1965, it was intended to protect individuals over the age of 65
from exorbitant costs of health care by providing public funds to cover the
majority of health care services. In 1972, Medicare was modified to include
permanently disabled individuals and those with end-stage renal disease.
Medicaid
Medicaid is the United States
health program for individuals and
families with low incomes and resources. It is an entitlement program that is
jointly funded by the states and federal government, and is managed by the
states.[1]
Among the groups of people served by Medicaid are eligible low-income parents,
children, seniors, and people with disabilities. Being poor, or even very poor,
does not necessarily qualify an individual for Medicaid.[2] Medicaid is the largest source of funding for
medical and health-related services for people with limited income.
Medicaid is a
shared venture between the federal and state governments. Each state has
latitude in determining who is “medically indigent,” and thus qualifies for
public monies. Minimal services covered by Medicaid are defined by the federal
government and include inpatient and outpatient hospital services, physician
services, laboratory services (including x-rays), and rural health clinic
services. States may elect to cover other services, such as dental, vision, and
prescription drugs.
Factors
influencing the delivery of health care
Despite cost-containment efforts (such as DRGs
established by the federal government and managed care by the insurers), the
Cost
Why is consideration of cost
so important? The very existence of the health care system depends on fiscal
issues
(O’Neil, 1993). Cost has been a driving force for change in the
health care system as evidenced by the strength and numbers of managed care
plans, increased use of outpatient treatment, and shortened hospital stays.
These market forces (to maximize profits by minimizing costs) are dominating
the current changes in the health care system.
The
The cost of providing health
care has risen dramatically during the past 20 years. Health care costs are
expected to consume 16.2% of the Gross Domestic Product (GDP) by the year 2008
(Health Care Financing Administration, 1997).
The health care bureaucracy has become mammoth.
The most cost-efficient programs in terms of administration are Medicare
and Medicaid because of the number of people eligible for these benefits. In
contrast, some private plans, particularly small business plans, use over 40
cents of each dollar for administration. The cost of health care is seriously
compromising American business and industry. For example, the chief executive
officer of Ford Motor Company stated that the costs for health care coverage of
employees exceeded the total expenditures on steel used in building cars (Grace
& Brock, 1994). This policy may lead businesses to invest less money in
growth and development, a decision that places the
The cost of employee health care benefits is an expensive commitment for
small businesses and is a serious factor when one considers that the economy of
this country has survived—if not thrived—because of the contributions of small
businesses.
Four major factors increase
the cost of health care:
·
an oversupply of
specialized providers,
·
a surplusof hospital beds,
·
the passive role
assumed by most consumers,
·
inequitable financing of
services (Grace, 1994).
Other factors that contribute
to the high cost of health care are the aging of the population, the increased
number of people with chronic illnesses, the increase in health-related
lawsuits that has resulted in the unnecessary use of services, and advanced
technology that has allowed more people to survive disabling illnesses.
Effects of Inflation
To
adjust for the effects of inflation health care costs should be counted in a base year. Where costs
are incurred over a period of years it is important to correct for the effects of inflation. Finally,
adjustment for inflation is required to provide real resource cost.
Here
is an example of how costs are adjusted for inflation. The table shows
alternative treatments for a hypothetical condition. The alternatives include
surgery or drugs.
Access
In addition to the issue of cost, access to health care services has a
serious impact on the functioning of the health care system. As a result of the
cost, health care for many people is crisis-oriented and fragmented. A large
number of Americans are unable to gain access to health care services owing to
low income or lack of insurance, and, therefore, their illnesses progress to an
acute stage before they seek intervention. Poverty often adversely affects an
individual's access to health care services. For example, limited
transportation (lack of an automobile or funding for public transit) interferes
with the ability to travel to health care facilities. Services used by
individuals during acute illnesses are typically those provided by emergency
departments. Emergency room and acute care services are expensive when compared
with early intervention and preventive measures. Approximately 43 million
Americans are uninsured (Falter 1999). Only a small portion
of the medicallyndigent are covered by
Medicare. In addition, many individuals are underinsured. These people are
neither poor nor old, but middle-class unemployed Americans or those in jobs
without adequate health care benefits.
In addition to poverty and unemployment, other factors impede a person’s
ability to obtain insurance. Refer to the accompanying display that lists
factors affecting access to health care services.
Other variables affecting access are the increase in the number of women
employed outside the home and the number of single-parent families. These
factors impair access to health care services because it is often difficult for
parents to take time off from work to transport children to health care
providers (Uphold &Graham, 1993).
Quality
It is estimated that 30% to 40% of diagnostic and medical procedures
performed in this country are unnecessary (Lee, Soffel,
& Luft, 1994). This inappropriate use of
resources can be traced to several causative factors, including:
·
The litigious environment that creates the ten dencytoward defensive practice
·
Resource consumption is highly influenced by the
widely held American belief that more is better
·
Lack of access to and continuity of services with
subsequent misuse of acute care services
In an attempt to provide universal access to services in a cost-effective
manner, quality does not have to be sacrificed. For example, hospitals that are
reducing the numbers of registered nurses (“downsizing”) risk endangering
quality. Safety and quality are frequently compromised by inappropriate
substitution of unqualified personnel for registered nurses in direct care of
clients. The Economic Policy Institute (1999) released a study that indicates
that, as more tasks are delegated to unlicensed assistive personnel (UAP), the
quality of data used in decision making diminishes.
A study conducted in 1998 revealed that 72% of nurses surveyed stated that
the quality of care provided at their hospitals had deteriorated because of
cost-containment measures. This reflects a 12% increase from 1988 similar
survey results (Wolfe, 1999). Cross-training of staff, increased use of
unlicensed personnel, and reductions in full-time positions for nurses are
affecting the type of care delivered in hospitals. In an attempt to be
cost-effective, some hospitals have decreased the number of registered nurses,
thereby creating unsafe situations for clients (American Nurses Association,
1995).
Microeconomics
Microeconomics is a branch of economics
that studies how individuals, households and firms make decisions to allocate
limited resources, typically in markets where goods or services are being
bought and sold. Microeconomics examines how these decisions and behaviors
affect the supply and demand for goods and services, which
determines prices; and how prices, in turn, determine the supply and demand of
goods and services.
Microeconomic deals with the
behaviors of individuals and organizations and the effect of those behaviors on
prices, cost, and the allocating the distributing of resources.
Macroeconomics,
on the other hand, involves the "sum total of economic activity, dealing
with the issues of growth, inflation
and unemployment,
and with national economic policies relating to these issues" and the
effects of government actions (such as changing taxation
levels) on them. Particularly in the wake of the Lucas
critique, much of modern macroeconomic theory has been built upon
'micro foundations' — i.e. based upon basic assumptions about micro-level
behavior.
Health care macroeconomic
issues are concentrated with issues such as the influences of health cost,
quality, access, and policies on the overall
One of the goals of
microeconomics is to analyze market mechanisms that establish relative prices amongst
goods and services and allocation of limited resources amongst many alternative
uses. Microeconomics analyzes market
failure, where markets fail to produce efficient results, as well as
describing the theoretical conditions needed for perfect competition. Significant fields of
study in microeconomics include general equilibrium, markets under asymmetric information, choice under uncertainty
and economic applications of game theory. Also considered is the elasticity of products within the market
system.
Trends affecting delivery of
health care services
·
The aging of the
·
Increased number of single-parent families, with more
children living in poverty
·
Continued growth in outpatient settings with a greater
demand for primary care providers
·
Advances in technology with a resultant ability to
perform more services in outpatient settings (including the home)
·
More states using managed care models to deliver
services to the medically indigent
·
More emphasis on disease prevention and health
promotion at the workplace
·
Expectations of third-party payers and providers for
clients to assume more personal responsibility for care
·
Incentives for individuals who participate in preventive activities
·
Federal funding of health care provider education
focusing on service to underserved populations and areas
·
The system as a union of both public and private
sector resources and services Managed care dominating as the context for
service delivery
·
The right for individuals to enhance a basic package
or expand their choices if they care to purchase that privilege Continuing
focus on quality improvement
Trends and issues
·
As current trends continue into the millennium, the delivery
of health care services will continue to change.
·
The accompanying display lists factors that will
continue to shape reform of the health care delivery system.
·
The states and private sector will lead the way
through a process to a product suited to the American character.
·
The nursing profession has reached a point in time
where there are few questions about the direction or process of health care
reform. As health care reform occurs, some professions will experience
opportunities while others will experience losses (O’Neil, 1993).
·
The challenge is to improve the nation’s delivery of
health care services by positioning nursing to preserve its integrity and
guarantee its preferred future. Nurses must continue to be in the forefront of
change.
·
Health care services are delivered by both the
public (official, voluntary, and
nonprofits agencies) and private
(hospitals, extended care facilities, home health agencies, hospices, outpatient settings,
schools, industrial clinics, managed
care organizations, community nursing
centres, and rural hospitals) sectors.
·
The health care team is composed of nurses, APRNs, physicians, physician assistants, pharmacists,
dentists, dietitians, social workers, therapists, and
chaplains.
·
Health care in the
·
Managed care organizations seek to control health care
costs by monitoring the delivery of services and restricting access to costly
procedures and providers. Managed care plans include health maintenance
organizations, preferred provider organizations, and exclusive provider
organizations.
·
The primary federal government insurance plans are
Medicare, the program that provides health care coverage for the elderly and
disabled, and Medicaid, the jointly administered program that provides health
care services for the poor.
·
Health care reform must address the three critical
issues of cost, access, and quality of health care services to achieve equity
for all Americans.
·
The cost of health care has been influenced by the
oversupply of specialists, a surplus of hospital beds, the passive role assumed
by most consumers, and the inequitable financing of health care services.
·
The challenges that the health care delivery
system need to overcome are the public’s
disillusionment with providers, the
public’s loss of control over health
care decisions, the decreased use of hospitals
and the related impact on quality of care, the change in practice settings, ethical issues, and the
health care needs of vulnerable
populations. ursing’s
Agenda for Health Care Reform, written by the American Nurses Association and endorsed by
over 70 professional organizations,
outlines nursling’s proposals for easing
the current problems in health care
delivery.
·
The Agency for Health Care Research and Quality aims
to identify therapeutic standards for which the health care community can be
held accountable.
·
For advanced practice nurses to continue to provide
access to high quality care, issues such as direct reimbursement for services,
prescriptive authority, comprehensive professional liability insurance,
autonomy in managed care plans, professional staff privileges in health care
facilities, and adequate practice acts need to be resolved.
A primary
goal of the nursing profession within the areas of public health, community
health, and long term care is to provide health care services that emphasize
prevention and primary health care to clients in these settings and thus help
reduce the cost and increase the quality of health care.
Health
care reform
Nevertheless, health care
reform is, and has been a hot issue for some time and is
likely to remain so until there has been additional progress in resolving some
of the basic issues that have been mentioned. Americans are conscious of, and
troubled by, the flaws with the system of providing health care and health care
reform is often on the minds of those who work in health care and for the
government.
It is
likely that health care researchers, policy makers, decision makers, as well as
the general public – who are taxpayers and consumers - will continue to seek improvements in health care and
that, in doing so; they may approach you for assistance in identifying and
retrieving health care expenditure and related data. To that end it is
important to take a closer look at major
funders of the health care system and at some
of the data available.
Innovation and
improvement of the health care system by reappraisal, amendment of services,
and removal of faults and abuses in providing and distributing health services
to patients. It includes a re-alignment of health services and health insurance
to maximum demographic elements (the unemployed, indigent, uninsured, elderly,
inner cities, rural areas) with reference to coverage, hospitalization, pricing
and cost containment, insurers' and employers' costs, pre-existing medical
conditions, prescribed drugs, equipment, and services.
Summary:
Health economics:
·
is a broad-based sub discipline of economics
·
is concerned with maximizing benefits within available
resources
·
overlaps with
a number of topics, both within and apart from, health and medicine
·
interacts with
many other disciplines
·
encompasses
more than economic evaluation alone
·
has a significant role in health care decision-making at policy and
clinical level
PREPARATION FOR COMMUNITY HEALTH
NURSING
The demands of
community health nursing practice are significant, as described in Chapter 1,
and are elaborated elsewhere in this textbook. The daily routine of the
community health nurse may include organizing a flu clinic for seniors in the
community, making home visits, giving a presentation on playground safety at a
parent-teacher meeting, participating in a team meeting in the health
department office, answering telephone calls, and charting. All of the skills learned
in a basic baccalaureate nursing program are needed to effectively manage this
type of day. Furthermore, this day may not represent the bigger picture of the
community health nurse’s role on community advisory panels, grant writing for new
programs, or participation in or presentation of inservice
programs. Academic preparation for this role is necessary, as is continuous
professional development, and this training must meet the requirements expected
by employers for people in this specialty in nursing and, in many instances, by
state regulations.
Academic
Preparation
The
minimum preparation for community health nurses in many states has been
graduation from a baccalaureate-level nursing program, a nursing major built on
2 years of liberal arts and sciences courses (Ellis & Hartley, 2000). This
can be achieved in a variety of ways. Some students enter a baccalaureate program
as their initial higher educational experience after high school or later. Others
complete an associate degree program in nursing and continue on to a university
to receive the baccalaureate degree. This requires additional courses in
liberal arts and sciences, along with selected nursing courses, usually one or
more courses in public health nursing and often critical care nursing and
leadership-management courses as well. In some programs designed to extend an
RN to a Bachelor of Science in Nursing (BSN), nurses with years of experience
in acute care nursing can “challenge” the previously mentioned courses by
taking a test to demonstrate clinical expertise or by presenting a portfolio of
experience, or a combination of these. Nevertheless, whatever the initial entry
into practice, a comprehensive nursing education that is rich in leadership, management,
research, health maintenance and promotion, disease prevention, and community
health nursing experience is needed to meet the demands of this specialty. In
some states, meeting criteria for entry into practice as a public health nurse
is required by some employers. In
Professional
Development
Completion
of a baccalaureate education may not be sufficient educational preparation for
the more demanding community health nursing settings. Furthermore, to maintain
licensure in most states, it is mandated that nurses participate in continuing
education programs and receive continuing education units (Ellis & Hartley,
2000). In the
Matriculation
in an NP program or a master’s degree program in nursing is a longer commitment
and gives the nurse greater marketability. In some health departments, NPs run
well-child clinics, and a school nurse with an NP license can direct a
school-based clinic. Advanced practice in community health nursing can open
doors into leadership positions in community health agencies. A master’s degree
in business, public health, education, or epidemiology can lead to management
positions, private community health agency ownership, agency teaching, or
research positions. A doctoral program may be the next educational step for
those wanting tenure-track university teaching, research, or upperlevel administrative positions.
The
American Nurses Credentialing Center (ANCC) provides other opportunities by
offering nurses certification in more than 45 specialty areas. There are two
specialties in community health nursing: a generalist certificate as a
community health nurse, and a clinical nurse specialist certificate in
community health nursing. Related certifications as an NP or in nursing
administration also exist. Each certificate is awarded after completion of a
certain number of years of practice in the specialty, payment of a fee, and
passage of an ANCC Certification Examination. When certification is awarded,
the nurse can sign as “RN,C.” Many employers reward the
initiative required for certification with promotion or a higher salary
accompanied by additional responsibilities and opportunities.
SUMMARY
The
specialty of community health nursing developed historically through four
stages. The early home care stage (before the mid-1800s) emphasized care to the
sick poor in their homes by various lay and religious orders. The district
nursing stage (mid-1800s) included voluntary home nursing care for the poor by
specialists or “health nurses” who treated the sick and taught wholesome living
to patients. The public health nursing stage (1900 to 1970) was characterized
by an increased concern for the health of the general public. The community
health nursing stage (1970 to the present) includes increased recognition of
community health nursing as a specialty field with focus on communities and
populations.
Six
major societal influences have shaped the development of community health
nursing. They are advanced technology, progress in causal thinking, changes in
education, the changing demographics and role of women, the consumer movement,
and economic factors such as health care costs, access, limited funds for
public health, and increased competition among health service providers.
Academic
preparation for community health nursing begins at the baccalaureate level. However,
students beginning at the diploma or associate degree level can advance to a
BSN completion program and then are prepared to enter this challenging
specialty in nursing. The demands of community health nursing require
additional courses in liberal arts and science, along with courses in community
health nursing practice at the student level. Once students achieve an
undergraduate degree, completion of additional educational programs is required
to keep current and, in most states, to maintain licensure, advance in practice
opportunities, or branch out into administration, teaching, or research.
References
·
American
·
American Public Health Association, Public Health Nursing Section. (1996).
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·
Association of State and Territorial Directors of Nursing. (2000). Public
health nursing: A partner for healthy populations.
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Backer, B. A. (1993). Lillian Wald: Connecting
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http://www.nih.gov, National Institutes of Health
http://www.turningpointprogram.org,
Innovative program to improve health in the
http://www.ncmhd.nih.gov/,
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http://www.who.int/whr/2006/en/,
The World Health Report is updated annually by WHO.