The Growing Need for Community-Based Health Care
As described, the shift in the settings for health care delivery is a result of changes in federal legislation, tighter insur-ance regulations, decreasing hospital revenues, and the develop-ment of alternative health care delivery systems. As a result of federal legislation passed in 1983 and 1997, hospitals and other health care providers are now reimbursed at a fixed rate for pa-tients with the same diagnosis as defined by diagnosis-related groups. Under this system, hospitals and other health care providers can cut costs and earn income by carefully monitoring the types of services they provide and discharging patients as soon as possible. Consequently, patients are being discharged from acute care facilities to their homes or to residential or long-term facilities at much earlier stages of recovery than in the past. Com-plex technical equipment, such as dialysis machinery, intravenous lines, and ventilators, is often part of home health care (Brown, 2000).
Alternative health care delivery systems, such as health main-tenance organizations, preferred provider organizations, and managed health care systems, have also contributed to the drive to control costs and the availability of health care services. These regulations have dramatically reduced the length of hospital stay and have led to patients being treated more frequently in ambu-latory care settings and at home.
As more health care delivery shifts into the community, more nurses are working in a variety of public health and community-based settings. These settings include public health departments, ambulatory health clinics, long-term care facilities, prenatal and well-baby clinics, hospice agencies, industrial settings (as occu-pational nurses), homeless shelters and clinics, nursing centers, home health agencies, urgent care centers, same day surgical cen-ters, short-stay facilities, and patients’ homes.
Nurses in these settings often deliver care without direct on-site supervision or the support of other health care personnel. They must be self-directed, flexible, adaptable, and tolerant of various lifestyles and living conditions. Expertise in independent decision making, critical thinking, assessment, and health educa-tion, and competence in basic nursing care are essential to func-tion effectively in the community-based setting (Brown, 2000; Pierson, 1999).
Community-based nursing is a philosophy of care of individ-uals and families. The care is provided in a community as the individual or family move among various kinds of service pro-viders outside of hospitals (Hunt, 2000). Although the phrase “community-based nursing” is often interchanged with “commu-nity health nursing,” a distinction should be made. The phrase “community health nursing” has generally been equated to “pub-lic health nursing.” Public health nursing is a specialty focused on total populations, although care may be given to individuals. Community-based nursing is broader and may incorporate com-munity health–public health nursing; it is focused on individuals and families rather than total populations. Community-based nursing also includes home health nursing, school health nurs
ing, and a host of other nursing services provided to individuals and groups in the community (Fig. 2-1).
Community-based nursing practice focuses on promoting and maintaining the health of individuals and groups, preventing and minimizing the progression of disease, and improving quality of life (Hunt, 2000). Although nursing interventions used by public health nurses may involve individuals, families, or small groups, the central focus remains promotion of health and prevention of dis-ease in the entire community. The actions of community health nurses may include provision of direct care to patients and families as well as political advocacy to secure resources for aggregate pop-ulations (eg, the aged population). The community health nurse may function as an epidemiologist, a case manager for a group of patients, a coordinator of services provided to an aggregate of pa-tients, an occupational health nurse, a school nurse, a visiting nurse, or a parish nurse. (In parish nursing, the members of the religious community—the parish—are the recipients of care.) The com-monality of these various roles is that the nurse maintains a focus on community needs as well as on the needs of the individual pa-tient. Community-based care is generally focused on the individ-ual or family; although efforts may be undertaken to improve the health of the whole community, the individual or family unit is the main focus. The primary concepts of community-based nursing care are self-care and preventive care within the context of culture and community. Two other important concepts are continuity of care and collaboration (Hunt, 2000). Some community-based nursing fields have become specialties in their own right, such as school health nursing and home health nursing.
Primary, secondary, and tertiary levels of preventive care are used by nurses in community-based practice. The focus of pri-mary prevention is on health promotion and prevention of illness or disease, including interventions such as teaching regarding healthy lifestyles (Hunt, 2000). Secondary prevention centers on health maintenance and is aimed at early detection and prompt intervention to prevent or minimize loss of function and inde-pendence; it includes interventions such as health screening and health risk appraisal. Tertiary prevention focuses on minimizing deterioration and improving quality of life. Tertiary care may in-clude rehabilitation to assist patients in achieving their maximum potential by working through their physical or psychological challenges (Hunt, 2000).
Home health care is becoming one of the largest practice areas for nurses. Because of the high acuity level of patients, nurses with acute care and high-technology experience are in demand in this field. Tertiary preventive nursing care, which focuses on rehabil-itation and restoring maximum health function, is a major goal for home care nurses, although primary and secondary preven-tion are also included in care. Health care visits may be intermit-tent or periodic, and telephonic case management may be used to promote communication with home care consumers.
Home care nursing is a unique aspect of community-based nursing. Home care visits are made by nurses who work for home care agencies, public health agencies, and visiting nurse associa-tions; by nurses who are employed by hospitals; and by parish nurses who voluntarily work with the members of their religious communities to promote health. Such visits may also be part of the responsibilities of school nurses, clinic nurses, or occupational health nurses. The type of nursing services provided to patients in their homes varies from agency to agency. Nurses working for home care or hospice agencies make home visits to provide skilled nursing care, follow-up care, and teaching to promote health and prevent complications. Clinic nurses may conduct home visits as part of patient follow-up. Public health, parish, and school nurses may make visits to provide anticipatory guidance to high-risk families and follow-up care to patients with communicable dis-eases. Many home care patients are acutely ill, and many have chronic health problems and disabilities, requiring nurses to pro-vide more education and monitoring to the patient and family to facilitate compliance.
Holistic care is provided in the home through the collabora-tion of a multidisciplinary team that includes professional nurses; home health aides; social workers; physical, speech, and occupa-tional therapists; and the physician (Touchard & Berthelot, 1999). The team provides health and social services with over-sight of the total health care plan by a case manager, clinical nurse specialist, or nurse practitioner. Parish nurses may work to pro-vide home care training to members of their congregations.
Health care services are provided by official, publicly funded agencies; nonprofit agencies; private businesses; proprietary chains; and hospital-based agencies. Some agencies specialize in high-technology services. Most agencies are reimbursed from a variety of sources, including Medicare and Medicaid programs, private insurance, and direct payments by patients. Each funding source has its own requirements for services rendered, number of visits allowed, and amount of reimbursement the agency will re-ceive. Many home health care expenditures are financed by Medicare and are affected by provisions of the Balanced Budget Act of 1997.
The elderly are the most frequent users of home care services. To be eligible for service, the patient must be acutely ill, home-bound, and in need of skilled nursing services. Nursing care in-cludes skilled assessment of the patient’s physical, psychological, social, and environmental status. Nursing interventions may in-clude intravenous therapy and injections (Fig. 2-2), parenteral nutrition, venipuncture, catheter insertion, pressure ulcer treat-ment, wound care, ostomy care, and patient and family teaching. The nurse instructs the patient and family in skills and self-care strategies and in health maintenance and promotion activities (eg, nutritional counseling, exercise programs, stress management).
Medicare allows nurses to manage and evaluate patient care for seriously ill patients who have complex, labile conditions and are at high risk for rehospitalization. The nurse serves as a casemanager and monitors the delivery of care provided to patients in their homes.