7COMPETENCY #5Works Within the Responsibility and Authority of the Governmental Public Health System
n Marjorie A. Schaffer with Bonnie Brueshoff and Raney Linck
Dan was recently employed as a public health nurse (PHN) by a county health department. After two months on the job, he is asked to assist other PHNs in responding to a recent outbreak of measles. All con-firmed cases to date are in the Somali population. Unfortunately, the Somali communities have been tar-geted with misinformation about vaccine risks and have subsequently struggled with low rates of MMR immunization.
Dan has never worked for the government. Through the orientation process, he begins to wonder whether he will ever understand how the different levels of government work together. He refers to his ori-entation materials for Population-Based Public Health Nursing Competency #5, which focuses on work-ing with governmental systems. He comments to his supervisor, Carol, “This competency has so many parts. How will I ever understand what all these terms mean for the work I am doing?”
DAN’S NOTEBOOKCOMPETENCY #5 Works Within the Responsibility and Authority of the Governmental Public Health System
Source: Henry Street Consortium, 2017(continues)
Copyright 2018. Sigma.
All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.
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148 PART II n Entry-Level Population-Based Public Health Nursing Competencies
Local Public Health Department:An“administrativeorserviceunitoflocalorstategovernmentconcernedwithhealth,andcarryingsomeresponsibilityforthehealthofajurisdictionsmallerthanthestate”(NationalAssociationofCountyandCityHealthOfficials[NACCHO],2016,p.12).
Public Health Infrastructure:Theunderlyingframeworkforthepublichealthsystem,whichincludes:1)aquali-fiedworkforce,2)up-to-datedataandinformationsystems,and3)capableagenciesforassessingandrespond-ingtopublichealthneeds(HealthyPeople2020,2017b).
Public Health Model:Focusesonthehealthofpopulations;concernedwithpromoting,protecting,andmaintainingthehealthofeverycitizen.
DAN’S NOTEBOOK (continued)
Taking Responsibility for Improving Population HealthPHNs work in all levels of government; in urban, suburban, and rural settings; and in a variety of community agencies and organizations. Federal, state, and local governments all provide essential resources for contributing to the public’s health. This chapter discusses how levels of government work together to promote public health and how PHNs deliver population-based public health services in these set-tings, agencies, and organizations.
How Are the Federal, State, and Local Levels of Public Health Connected?At the federal level, the U.S. Department of Health and Human Services (DHHS) oversees many other agencies that focus on the health and well-being of U.S. citizens. One of these agencies is the Centers for Disease Control and Preven-tion (CDC). The CDC keeps track of disease outbreaks and health statistics and protects the health and quality of life for U.S. populations. The CDC website is a good source for statistics and other information you need for public health interventions. For example, a PHN could use the CDC web-site to find updated statistics on state and national obesity trends and evidence-based strategies for obesity prevention.
Other agencies that come under the DHHS umbrella oversee Medicare and Medicaid Services; research and healthcare quality; substance abuse and mental health ser-vices; and the safety of food, cosmetics, medications, bio-logical products, and medical devices. For example, a PHN could access information on food-safety alerts, such as the
contamination of ground beef (salmonella, typhimurium) and salad bars (norovirus).
State health departments often work with both federal and local levels of government. State health departments regulate facilities and organizations that influence health and health services. Examples of healthcare facilities reg-ulated by the state include hospitals, clinics, and nursing homes. State functions include financing and administering programs (Stanhope & Lancaster, 2016) and offering tech-nical assistance to local health departments for program development and services. The organization and functions of state healthcare departments can differ greatly among the states. Regardless of the organizational structure, a strong partnership between state and local health departments is essential to promote and protect the health of populations.
Local public health departments (LHDs) include both city and county health departments. They get directives from the state and federal levels and report to their local elected board members. Local agencies display consider-able variability in the populations they serve and how they accomplish their work. Table 7.1 identifies characteristics of LHDs found in the 2016 National Profile of Local Health Departments report (NACCHO, 2016).
LHDs often take actions to comply with state health department regulations and federal guidelines. In Dakota County in Minnesota, when a PHN received a report on a suspected case of measles, the PHN (local level) documented information from the Minnesota Department of Health (state level) and followed up on the measles contacts. The PHN reached all contacts and recommended contacts be in quarantine for the incubation period for showing symptoms of measles. In addition, relevant surveillance activities were
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149CHAPTER 7 n Competency #5
conducted by the PHN per MDH (state) and CDC (federal) guidelines.
On the Healthy People 2020 website, go to “Topics and Objectives,” and under “P” click “Preparedness.” Government agencies, nongovernmental organizations, the private sector, communi-ties, and individuals work together to “strengthen and sustain communities’ abilities to prevent, protect against, mitigate the effects of, respond to, and recover from incidents with negative health effects” (Healthy People 2020, 2017a, para. 1). What are some ways that PHNs can use the information in this section to contribute to accomplishing this goal? Think about actions that will address the needs of individuals, families, and communities during a major health incident. Which levels of government will be involved in PHN responses? See Table 7.2 in this chapter.
How Do the Essential Public Health Services and Core Functions Guide the Public Health Department and Your Work as a Public Health Nurse?In the United States, PHNs and other public health profes-sionals who work for governmental public health agencies have a scope of practice based on core public health functions and the essential services of public health (Institute of Med-icine [IOM], 1988).
TABLE 7.1 Characteristics of Local Health Departments
LHD Characteristic Data
Populations served n Fewer than 50,000 persons: 61% of LHDsn 500,000 or more: 6% of LHDs
Per capita expenditures n 2008: $63 per personn 2016: $48 per person
Examples of partners n Emergency responders (98% of LHDs)n K–12 schools (98% of LHDs)n Hospitals (95% of LHDs)n Media (95% of LHDs)
Registered nurses n 94% of LHDs employ registered nursesn Median number of nurses ranged from 1 in LHDs serving populations under 10,000 to 542
for LHDs serving populations greater than 1 millionn Registered nurses comprise 18% of the LHD workforce (not all are PHNs)n Overall percentage of nurses decreased by 28% between 2008 and 2016, related to health
department budget cuts for programs and staffing
Other public health staff in LHDs
n 91% of LHDs employ office and administrative support staffn Larger LHDs also often employ epidemiologists, statisticians, information systems specialists,
public information professionals, health educators, and public health physicians
Source: NACCHO, 2016
EVIDENCE EXAMPLE 7.1Three Levels of Government Working Together in Emergency Preparedness
LHDs work with the state and federal levels of govern-ment to provide emergency preparedness services. Atthe local level, 45% of LHDs reported they responded toanall-hazardseventinthepastyearand90%participatedinanemergencypreparednessexercise(NACCHO,2016).PHNs have specific skills for preparing for and respond-ingtodisasters.Inadditiontoactingasfirstrespondersindisaster events, PHNs use a population approach to col-laborate on policy development, disaster response plans,and disasterdrillsand training (Jakeway,LaRosa, Cary,&Schoenfisch(2008).PHNscontributetothefollowingfourdisasterphases(Jakewayetal.,2008,p.355):
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150 PART II n Entry-Level Population-Based Public Health Nursing Competencies
TABLE 7.2 Emergency Preparedness Example
Local State Federal
Planning LHDs write all-hazards plans to direct local emergency responses, including staffing of Open Points of Dispensing (PODs), communi-cations with the public and other partners, and Department Opera-tions Center (DOC) on setup and procedures.
LHDs conduct exercises to test plans in order to practice skills and identify areas for improvement.
The state health department consults with LHD on plans and writes grant requests regard-ing required plan elements and required exercises that need to be completed in order to receive grant funding.
The Centers for Disease Control and Prevention (CDC) is the funding source for both state and local health departments. The CDC creates and conducts a biannual assessment, the Operational Readiness Review, to measure the overall status of both state and local preparedness around the 15 Public Health Preparedness Capabilities.
Prevention and Risk Mitigation
LHDs complete a Hazard and Vulnerability Assessment with Emergency Management to evalu-ate greatest risks in the jurisdiction (geographical area). Based on those risks, the LHD can do community outreach and provide trainings to mitigate some of the adverse effects of different emergencies.
The state health department regularly communicates and meets with LHD staff to provide training and consultation and interpret CDC guidance. The state employs regional consultants to individ-ually work with the LHDs and coordinate risk and prevention activities across the region.
The CDC stockpiles medications and supplies based on assessed public health risks such as a future influenza pandemic, bioterrorism, or emerging infectious agents. These are called Strategic National Stockpiles (SNS). The CDC also funds development of vaccines and other prophylactic pharmaceuticals to prepare for future needs.
Response The LHD sets up a Department Operations Center from which the Incident Command will run the response to a Public Health Emergency. This response could be staffing a hotline, communicat-ing with the public, setting up a shelter, or dispensing prophylactic medication or vaccine through a Point of Dispensing (POD).
The state public health agency provides situational updates, subject matter experts, and emer-gency messaging to the public. The state can request emergency medications, vaccines, equipment, and supplies from the Strategic National Stockpile and push that out to the LHD to dispense to the public.
The CDC interacts with interna-tional partners to coordinate inter-national public health emergency responses, such as the 2015 Ebola outbreak. The CDC also can help deploy staff to state and local part-ners for assistance. This is called the Epidemic Intelligence Service (EIS). They have medical response teams available to assist state and local partners when local resources are depleted.
PHN Role PHNs working in LHDs hold lead-ership roles in incident command and can provide subject matter expertise regarding the health implications of an emergency. At a Point of Dispensing, nurses staff the roles of screening (assessing for contraindications, allergies, or drug interactions), dispensing, and education.
PHNs working at the state help provide subject matter expertise around infectious pathogens, mass dispensing guidelines, and public health interventions. The majority of emergency preparedness work at the state level falls under the population-based section of the Public Health Intervention Wheel. Many emergency preparedness interventions are consistent with the PHN role.
PHNs at the CDC are involved in many preparedness roles, including serving as experts in vaccine guide-line development. PHNs are part of the disease response teams at the national level that are deployed to local responses as needed. Nurses serve in leadership roles in emer-gency preparedness and planning as well.
Contributed by Christine Lees, MPH, BSN, PHN, Dakota County Public Health and Amalia Roberts DNP, RN, PHN, Dakota County Public Health
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151CHAPTER 7 n Competency #5
Figure 7.1 demonstrates the relationship between the core functions and the essential services that government agen-cies and their staff must carry out (Source: CDC, 2014).
The three core functions are:n Assessment: Community assessment of population
health needs by monitoring and investigating levels of population health and illness
n Policy Development: Development of health policies, goals, plans, and interventions to meet priority commu-nity health needs
n Assurance: Measurement of outcomes of health poli-cies, goals, plans, and interventions and the competency and adequacy of public health professionals to deter-mine whether a community’s priority health needs have been met in an efficient, effective, and timely manner
The Ten Essential Services of Public Health (CDC, 2014) in Figure 7.1 need to be carried out by PHNs and other public health professionals to maintain the health of a community and its diverse populations. Table 7.3 outlines these essential services and provides examples of each.
TABLE 7.3 Ten Essential Services of Public Health, With Examples
Essential Service Example
1. Monitor Health n Carry out community assessment to determine levels of health and illness in community and populations.
2. Diagnose and Investigate n Check lead levels of preschool children, infants, and toddlers at risk for lead poisoning.n Offer diabetes screening in the Native American community.
3. Inform, Educate, and Empower
n Teach first-time parents how to care for their new baby.n Provide car seat education to new parents.
4. Mobilize Community Partnerships
n Develop a network of community services for elderly people within the community.
5. Develop Policies n Work with county board members to develop a policy for playground safety in local communities.
6. Enforce Laws n Report suspected child abuse or neglect.n Monitor compliance with immunization laws for school children.
7. Link to/Provide Care n PHNs and emergency department staff develop a referral and follow-up system for homebound elderly who visit the emergency department and then return home.
8. Assure Competent Workforce
n Update public health nursing staff on the influenza virus.n Teach rural PHNs how to do well-water testing.n Precept nursing students.
9. Evaluate n Carry out evaluation studies to determine the effectiveness of public health nursing programs, such as home visiting to new families.
n Evaluate programs that LHDs contract with for service provision.
10. System Management and Research
n Determine needs for public health services and service gaps in the community.n Provide data to justify claims that tax dollars improve the public’s health and demonstrate a
return on investment.
Source: CDC, 2014
FIGURE 7.1 Essential Public Health Services and Core FunctionsSource: CDC,2014
Link to/Provide Care
152 PART II n Entry-Level Population-Based Public Health Nursing Competencies
The following section shows how PHNs accomplish the work that is outlined in the essential services and core func-tions and contribute to the well-being of populations. In a survey of 57 PHNs working in local and state governments and representing 28 states, they identified the amount of time spent providing each of the essential services. The per-centage of time spent on each essential service ranged from 7% to 14% (Keller & Litt, 2008). See Figure 7.2.
Dan remembers seeing the Public Health Core Functions in his orientation manual—assessment, policy development, and assurance. He says to Carol, “Let’s see if I understand how this works.”
“For the measles outbreak, I can see assessment hap-pening when we are identifying how many children in the targeted age group live in our county. For policy develop-ment, we are following the directives given by the CDC and the state department of health for vaccine administration. I can see how we are working with and through others to ensure that as many children as possible have access to the vaccine. Assurance occurs when we make sure the vaccine is accessible to the population groups that need to be vacci-nated and that the vaccine has been administered to them.”
Carol affirms Dan’s analysis of how the core functions were represented in the response efforts to the measles out-break. Dan then says, “I am not sure about all those essen-tial services. Do PHNs conduct all ten in response to the measles outbreak?”
Carol answers, “Let’s analyze how each of the essential services occurs when our health department responds to the measles outbreak. Let’s develop a handout to put into the orientation manual to help everyone understand how we are providing the essential services.”
See Table 7.4 for the handout that Dan and Carol developed.
Application of Ten Essential Services to Measles Outbreak ResponseA measles outbreak occurred in Minnesota in late March of 2017. This was the worst measles outbreak in Minnesota since 1990. A total of 79 cases were reported, which primar-ily affected the Minnesota Somali community. All local health departments in Minnesota had a role in prevent-ing the spread of this infectious disease, involving activi-ties such as active awareness and risk communication with medical providers.
How Do Public Health Nurses Use Statutory Authority?Statutory authority refers to the statutes (laws) and rules through which the government gives authority to agencies to carry out specific duties. In the public health arena, PHNs are responsible for adhering to public health laws that have been enacted to protect and promote the health of commu-nities. Public health laws may be federal, state, or local, but many are implemented at the local level.
Public health law is often established in response to crit-ical public health problems that affect populations. Mello and colleagues (2013) identified three criteria for determin-ing opportunities for establishing public health law: 1) the
EVIDENCE EXAMPLE 7.2National Public Health Accreditation
In 2011, a national voluntary accreditation program forlocal,state,territorial,andtriballeaderswasestablishedtoensureaccomplishmentoftheCoreFunctionsandtheTenEssentialServices.ThePublicHealthAccreditationBoard(PHAB) oversees the accreditation process. Participationin the accreditation process helps health departments toidentify their strengthsandweaknesses;establishqualityimprovementstrategies;communicatetheiraccountabilityto community members, stakeholders, and policymakers;andbecompetitiveinfundingopportunities(CDC,2017b).
FIGURE 7.2 Percentage of PHNs’ Time Dedicated to Essential Services (n = 57)
7%Enforce laws& regulations
153CHAPTER 7 n Competency #5
TABLE 7.4 Ten Essential Services: Measles Outbreak Response by Local Public Health
Essential Service Application Example
1. Monitor health Monitored data on those at risk due to being unvaccinated, and monitored clinic and hospital data of reported cases provided by Minnesota Department of Health
2. Diagnose and Investigate Communicated with summer camps and daycares on symptoms to watch for and resources available
3. Inform, Educate, and Empower
Worked with local media outlets and sent a Health Advisory to medical providers on the outbreak, including what to watch for and report
4. Mobilize Community Partnerships
Worked with Somali community leaders and organizations to reach the at-risk population
5. Develop Policies Adopted policies from CDC and state department of health on vaccine recommendations
6. Enforce Laws Activated response by utilizing the Health Department Emergency Response Plan
7. Link to/Provide Care Coordinated with the Department of Human Services regarding childcare licensing regulations and potential changes needed due to outbreak
8. Ensure Competent Workforce
Provided training for staff to assist with contact investigation and follow-up to ensure competence for roles and responsibilities
9. Evaluate Once outbreak was over, a “hot wash” was conducted to document the response work and lessons learned
10. System Management and Research
CDC vaccine information posted on website, which included basic information and vaccination guidance
law targets a significant public health problem, 2) factors contributing to the public health problem are understood well enough to change behavior through law, and 3) a feasi-ble intervention can be implemented.
Public health law is potentially an effective tool for improving population health outcomes. However, compet-ing interests and values about laws may affect individual choice. This adds complexity to enacting laws that address threats to individual and population health. It is important to provide objective and timely evidence to support legal policy that contributes to improving population health. Major trends in public health law and practice include the following focus areas (Hodge et al., 2013): n The Affordable Care Actn Emergency legal preparednessn Health information privacy and data sharingn Tobacco controln Drug overdose protectionn Food policyn Vaccination requirements and exemptionsn Sports injury law and policyn Public health accreditationn Maternal and child health
Public health laws influence funding for public health programs. For example, emergency preparedness programs received major funding following bioterrorism events and threats. Funding increases the number of public health prac-titioners employed in emergency preparedness programs.
Public health laws also protect the health of the public. PHNs need to understand public health law and how it pro-tects individual, family, and community safety. Laws con-cerned with public health include public health nuisance; quarantine; mandated reporting of communicable disease; mandated reporting of suspected abuse and neglect of chil-dren, the disabled, and the elderly; and commitment. See examples of local public health laws in Table 7.5.
The Network for Public Health Law (https://www. networkforphl.org/) compiles information and resources about public health law at all levels of government. It iden-tifies primary legal issues and offers technical assistance for a variety of topics.
154 PART II n Entry-Level Population-Based Public Health Nursing Competencies
TABLE 7.5 Public Health Law Examples
Type of Law Key Features Example
Civil commitment Protects mentally ill individuals from danger to themselves or others; addresses process of obtain-ing a court order to obtain treatment for mental illness when individuals are unable or unwilling to seek treatment voluntarily and need protection from harming themselves or others due to illness. Civil commitment laws vary across states.
PHNs collaborate with family members, other health professionals, community agencies, and the government in the civil commitment process by providing information about the process and referring to resources.
Data privacy The federal government administers the Health Insurance Portability and Accountability Act (HIPAA) of 1996. PHNs are accountable for ensur-ing the data-privacy aspect of HIPAA. In some states, laws specify that information important for ensuring public health can be disclosed.
Minnesota’s Data Sharing Law allows the sharing of immunization data with schools and childcare providers without parental permission. Healthcare providers can share information about commu-nicable diseases with the state health department without patients’ permission. Otherwise, the sharing of individual and family healthcare infor-mation requires that clients sign a release of infor-mation form authorizing sharing of information.
Mandated reporting of suspected child abuse or neglect
Professionals in relevant disciplines who have a reason to believe a child is being neglected or abused are obligated to report the information to the local welfare agency. Many states also offer civil immunity for people who make reports, and penalties if suspected child abuse is not reported (Pozgar, 2005).
PHNs are mandated reporters for suspected child abuse and neglect.
Mandated reporting of communicable disease
Mandates reporting of communicable diseases so that occurrence of the disease can be monitored.
During the H1N1 epidemic in 2009, surveillance of incidence of H1N1 cases helped determine the number of flu clinics to be offered and whether schools needed to close.
Public health nuisances
Include conditions that threaten the health of the public and require response or action from the local health department. Examples are: garbage accumulation, sewage, noise, junked cars, aban-doned swimming pools, rodent infestation, and faulty electrical wiring or plumbing.
Top three complaints were mold, garbage houses, and accumulation of rubbish or junk (MDH, 2017c).
Quarantine Provides for isolating individuals or groups to pre-vent the spread of communicable disease; restricts activities or travel of an otherwise healthy person with possible exposure to a communicable disease to prevent disease transmission.
Can be used to reduce the effects of bioterrorism or pandemic events, such as the spread of avian influenza or Ebola.
School-entry laws Mandate evidence of vaccination for specific com-municable diseases or a legal exemption signed by a parent.
School-entry laws, in place since the 1960s, have led to increased vaccination rates and decreased rates of childhood communicable diseases (Horlich, Shaw, Gorji, & Fishbein, 2008). Some parents might object to compulsory vaccinations for their children because of medical reasons or religious/cultural beliefs.
Sources: Minnesota Department of Health, 2003, 2005, 2015, 2016, 2017a, 2017b; Minnesota Department of Health State Community Health Services Advisory Committee, 1992; National Alliance on Mental Illness, 2016; Office of the Reviser of Statutes, 2016
155CHAPTER 7 n Competency #5
TABLE 7.6 Differences Between the Public Health and Medical Models
Public Health Model Medical Model
Mission is to promote, protect, and maintain the health of every citizen.
Mission is to restore health to those who seek care (i.e., treatment and cure).
Focus is on the primary health needs of communities and populations.
Focus is on the primary health needs of individuals.
Health seen as a birthright of every citizen. Healthcare seen as a service to be sought.
Goal is client/family and population self-sufficiency. Goal is providing quality service to meet immediate medical care needs.
Focus is on prevention. Focus is on treatment.
Seeks to protect the public’s health before problems arise. Seeks to meet the needs of patients who present for care of an existing problem.
Reaches out to identify individuals, families, and populations with service needs (case-finding).
Addresses the needs of patients who present for care.
Focus is on populations, the community, and the family. Focus is on the individual.
Provides services that others cannot or will not provide. Generally provides services that are reimbursable.
Seeks social change to improve the health status of populations.
Seeks change to improve health status of an individual.
Provides services primarily in community settings. Provides services primarily in healthcare facilities.
Provides health-promotion services in the home and might provide services to meet medical needs or refer those individ-uals with medical needs to a home care agency.
Provides home care services for medical needs related to disease and disability.
THEORY APPLICATIONComparison of the Public Health and Medical Models
As you think about how government organizations guideanddeliverpublichealthservices,and the responsibilitiesofthegovernmentandPHNsfor improvingthehealthstatusofindividualsandpopulations,considerhowPHNsuseapublichealthmodelincontrasttoamedicalmodel.Onedifferenceisthatthepublichealthmodelfocusesonpopulations,whereasthe medical model focuses on individuals. Another differ-ence is the public health focus on prevention of disease asopposedtothemedicalmodelfocusontreatmentofdisease.In the public health model, healthcare is viewed as a right,whereas inthemedicalmodel,healthcare isaservice.PHNscanuse thepublichealthmodel tohelp frame theirpracticeas prevention-oriented and population-based. See Table 7.6.Considerhowthepublichealthmodeldiffers fromthetradi-tionalmedicalmodelwhenplanninginterventionstoimprovehealthstatusamongpopulationstoensurethatinterventionsareconsistentwiththemissionofpublichealth. Someservicesareprovidedinbothpublichealthandmed-ical settings, but their approaches to healthcare differ. Forexample, childhood screening is provided in public health
programstoimprovethewell-beingofthepopulationofchil-dren in the community. Fromthe perspective of the medicalmodel, an individual child is screened on routine visits in aclinictoevaluatethatchild’shealthstatus. In2008,theMinnesotastatelegislaturesignedintolawtheStatewide Health Improvement Program, changed to State-wide Health Improvement Partnership in 2017 (SHIP). SHIPisdesignedtoreducerisk factors forchronicdisease; reduc-ing these risk factors ultimately decreases healthcare costs.Partnership strategies engage communities in implementingevidence-based interventions to reduce obesity and tobaccouse. SHIP awards community-level grants to support publichealthsolutionsinMinnesotacounties.SinceSHIPstrategieshavebeen implemented, theadultobesityrate inMinnesotahas decreased in comparison to obesity rates in surround-ing states from 27.6% in 2014 to 26.1% in 2015 (MinnesotaDepartmentofHealth,2017d).Manypartnersworktogetherto improve health, including schools, businesses, apartmentownersandmanagers,farmers,hospital,clinics,faithcommu-nities,andlocalgovernment.
156 PART II n Entry-Level Population-Based Public Health Nursing Competencies
How Do the Scope and Standards of Public Health Nursing Guide the Public Health Nurse in Independent Practice? The great majority of interventions implemented by PHNs represent independent nursing practice and are consistent with interventions delineated by the Public Health Inter-vention Wheel. Public Health Nursing: Scope and Standards of Practice, published in 2013 by the American Nurses Asso-ciation, is also important for guiding the professional role expectations and actions of PHNs (see Chapter 1). The docu-ment has two sections—standards of practice and standards of professional performance. The standards of practice detail how the nursing process is applied in public health nursing. Table 7.7 analyzes how each of these role expecta-tions occurred in the response to the measles outbreak.
How Is the Government Involved in the Delivery of Community Health Services?Often, governmental organizations collaborate with private and nonprofit organizations to deliver community health services. Governmental organizations may provide funding, oversight, consultation, and other resources to support the public health work of private and nonprofit organizations. How do the core functions of assessment, policy develop-ment, and assurance take place in the following evidence examples?
After the flurry of responses to the measles outbreak had subsided, Dan reflects on how his work differs from that of his previous position as a nurse for a pediatric clinic. Dan comments to his supervisor, Carol, “I never realized how the government is responsible for public health. I now think about people who need the MMR vaccine not as individu-als, but as populations. We prioritized which populations were at risk. We also made sure that the vaccine was avail-able to everyone, regardless of whether they could pay for the vaccine. In the clinic, we followed a medical model that approached clients as individuals.”
Carol adds, “Yes, the public health model is oriented to finding people who need health services rather than always waiting for people to identify their needs. In addition, pub-lic health is oriented toward changing health and social systems to create environments that encourage improve-ment in health status. By reaching out to those populations most in need of the vaccination, we have actually created an environment that will help keep people healthy in the communities served by our agency.”
EVIDENCE EXAMPLE 7.3Childhood Obesity Prevention
AprograminSchoolDistrict197inDakotaCounty,Minnesota,isconsistentwiththepublichealthmodelapproach.SHIPfund-ingwasawardedtotheschooldistricttoencouragestudentstoeatavarietyoffruitsandvegetables.Theprogramisbasedonthe followingpremises: 1)obesitycontributes todiseasesthat affect a population (heart disease, diabetes, and otherchronicdiseases);2)diseaseandhealthproblemsresultfromindividualvulnerabilityandenvironmentalfactors,and3of5Minnesotansareoverweightorobeseduetoinsufficientphys-icalactivityandunhealthyeating(MinnesotaDepartmentofHealth,2017d);and3)interventionsshouldbetargetedtowardchangingenvironmentalfactors.Interventionsinclude:
Schoolnursesandparentsreportedchildrenwerewillingtotrynewfoods.StacieO’Leary, thehealthservicecoordinator fortheschooldistrict,observedtheprojectgoalledtomakinganenvironmentalchangeintheschooldistrict.
157CHAPTER 7 n Competency #5
TABLE 7.7 Standards of Professional Performance—Application to Measles Outbreak in Minnesota
Ethics Recognized that the outbreak is about unvaccinated children versus specific communities or ethnic groups
Education Provided education materials to childcare centers and summer camps on signs and symptoms of measles and where to refer to for any concerns
Evidence-Based Practice and Research
Accessed information from the CDC for vaccine safety and adverse reactions
Quality of Practice Adhered to CDC vaccination recommendations, including the exceptions to be made for providing earlier vaccinations per CDC
Communication Held meetings in communities with populations at risk to dispel the misinformation about vaccine risks, including the Somali community where key Somali leaders were involved
Leadership Activated Incident Command Structure to coordinate the response and work with local organizations
Collaboration Worked with MDH and other LHDs to provide outreach and surveillance to the population at risk
Professional Practice Evaluation
Completed After Action/Improvement Plan that follows guidelines from the Homeland Security Exercise and Evaluation Program
Resource Utilization Worked with the Minnesota Vaccines for Children Program that provides free or low-cost vaccines for eligible children through age 18
Environmental Health Promoted practices that reduced exposure to those most at risk within the community
Advocacy Provided outreach throughout the county to promote and encourage measles vaccination and communicate clinic schedules
EVIDENCE EXAMPLE 7.4Government Collaboration With Communities
158 PART II n Entry-Level Population-Based Public Health Nursing Competencies
What Should the Public Health Nurse Know About the Healthcare System?The United States healthcare system is financed by a com-bination of public and private entities that provide services to insured, underinsured, and uninsured populations. Private healthcare organizations may be for-profit or non-profit. Many government programs provide services using a combination of federal, state, and local funds. Local health departments often provide services to low-income residents. PHNs can assist community residents with referrals to clin-ics that are free or have sliding fee scales and connect them with insurance navigators for accessing healthcare coverage.
Table 7.8 identifies major programs and funding sources in the U.S. Healthcare System.
The ACA included provisions for health promotion ini-tiatives to contribute to better health outcomes and reduce costs. As part of the ACA, the National Prevention Strategy: America’s Plan for Better Health and Wellness (National Prevention Council, 2011) has four major strategies:
1. Building healthy and safe community environments 2. Expanding quality preventive services in clinical and
community settings 3. Empowering people to make healthy choices 4. Eliminating health disparities
The seven priority areas are: (1) tobacco-free living, (2) preventing drug abuse and excessive alcohol use, (3) healthy eating, (4), active living, (5) injury and violence-free living, (6) reproductive and sexual health, and (7) mental health and emotional well-being. The National Prevention Strategy identifies evidence-based recommendations for reducing the incidence of preventable death and major illness.
Several other federal agencies are responsible for oversee-ing health research, dissemination of health information, and
Mobile Outreach Nurse-Led Clinic USA
GOAL 9 Nursesarefirsthandwitnessestoclientneedsandhealthcaresystemchallenges,whichposi-tionsthemtocreateinnovativesolutions.ElisabethKnight,anursepractitioner,bringshealthservicestoruralandlow-incomeareasofsouthernArizona,wheremanylackaccesstohealthcareandinsur-ance.Alongwithamedicalassistantandadriver,Elisabethprovideshealthclinicsinatruckequippedwithexamroomsandalab.Servicesincludepreventativecare,basicwellnessadvice,managementofchronicconditions,andprenatalandbirthcaretoexpectantmothers.TheArizonalegislatureprovidedfundingforthemobileclinic.TheCollegeofMedicineattheUniversityofArizona,Tucson,overseestheprogram.Themobileclinicserves2,400peopleyearly;everyoneisaccepted,regardlessoftheirincome
health regulations to protect public health and safety. These include (Mossialos, Djordjevic, Osborn, & Sarnak, 2017): n Centers for Disease Control and Prevention:
Conducts research and programs to protect public health and safety
n National Institutes of Health: Oversees biomedical and health-related research
n Health Resources and Services Administration: Supports strategies to improve healthcare access
n Agency for Healthcare Research and Quality: Conducts evidence-based research
n Food and Drug Administration: Regulates food, tobacco products, pharmaceutical drugs, medical devices, and vaccines
Because of the high cost of healthcare, service delivery is changing. New ways of structuring healthcare aim to improve health outcomes and reduce costs. Recent initia-tives include (Mossialos et al., 2017):n Healthcare or Medical Home: A patient-centered
model that emphasizes care coordination and continuity of care.
n Accountable Care Organization (ACO): Provider networks that take on contractual responsibility for providing quality care for a defined population.
n Bundled payments: Organizations providing care are reimbursed with a single payment for all services deliv-ered by multiple providers for a single episode of care, such as surgical or chronic illness care.
In addition, the U.S. healthcare system has implemented special Information Technology infrastructures to maintain public health in four areas. See Table 7.9. A program called Electronic Health Record (EHR) Meaningful Use is creating a secure electronic reporting infrastructure for real-time
159CHAPTER 7 n Competency #5
TABLE 7.8 Major U.S. Healthcare System Programs and Funding
Centers for Medicare and Medicaid Services (CMS)
Established by Congress in 1965 fol-lowed by many incremental legislative changes
Federal agency administers Medicare, a federal program for adults 65 and older and some people with disabilities.
Works in partnership with state governments to administer Medicaid.
The Affordable Care Act (ACA)
Established by Congress in 2010
“…established ‘shared responsibility’ between the government, employers, and individ-uals for ensuring that all Americans have access to affordable and good-quality health insurance. However, health coverage remains fragmented, with numerous private and public sources, as well as wide gaps in insured rates across the U.S. population” (p. 173).
The ACA gives states the option of expanding Medicaid through subsidies from the federal government.
Private insurance—individual or employer
Regulated at state level.
“In 2014, state and federally administered health insurance marketplaces were estab-lished to provide additional access to private insurance coverage, with income-based premium subsidies for low- and middle-income people” (p. 173).
Medicare beneficiaries have the option of purchasing private supplemental insurance to cover additional health services and cost-sharing.
Source: Mossialos et al., 2017
TABLE 7.9 Public Health IT Structures
Public Health Reporting System Description
Syndromic Surveillance (SS) SS examples include monitoring for injury trends, such as bicycle accident–related inju-ries; tracking the burden of disaster-related conditions in hospitals following a natural disaster, such as a tornado; and tracking the severity of asthma and upper respiratory tract infections during allergy season.
79% of local health departments (LHDs) have implemented in 2016, with 3% in process.
Immunization Information Systems (IIS)
Creates a centralized repository of all immunization data with two-way electronic record exchanges that include sending and receiving immunization histories for individuals and related demographic information, as well as observations about an immunization event, such as reactions or eligibility for a funding program.
85% of local health departments (LHDs) have implemented in 2016, with 3% in process.
Electronic Laboratory Reporting (ELR) State and local laws require the reporting of particular lab results to public health agen-cies regarding communicable diseases such as anthrax, botulism, smallpox, and more. Through reporting, these agencies can act quickly to control the spread of the disease (e.g., vaccinating or treating close contacts of a patient, identifying contaminated foods, or uncovering industrial practices that cause toxic exposures).
49% of local health departments (LHD) have implemented in 2016, with 8% in process.
Cancer Registry Population-based cancer surveillance is essential for coordination of care, activities, and resource allocation to decrease the mortality and morbidity of this disease, which is the second-leading cause of death in the United States.
Cancer registries exist in all 50 states, Washington D.C., Puerto Rico, and the U.S. Pacific islands.
Sources: CDC, 2013, 2017a; Georgia Department of Health, 2017; International Society for Disease Surveillance, 2012; NACCHO, 2016; Savage, 2011
160 PART II n Entry-Level Population-Based Public Health Nursing Competencies
analysis. The goal is that whenever a provider charts health-care data in a hospital or clinic EHR, the data is automati-cally submitted to public health agencies. This provides an early warning system for bioterrorism, communicable dis-ease outbreaks, as well as insights in how to prepare for and provide better care during extreme weather events and mass gatherings like major sporting events (Yoon, Ising, & Gunn, 2017).
The Institute for Healthcare Improvement (IHI) devel-oped the Triple Aim Initiative as a framework for improv-ing health system performance. The three dimensions that healthcare policymakers need to pursue are: 1) improving the patient experience, 2) improving the health of popula-tions, and 3) reducing the per capita cost of healthcare (IHI, 2017). See Figure 7.3.
EVIDENCE EXAMPLE 7.5ACA Outcomes
Since implementation of the ACA, access to healthcarehas increased in the United States. The groups with thegreatest gains in access include young adult, Hispanic,black, and low-income populations, which demonstratessome progress in reducing health disparities. In addition,cost control measures have reduced some expenses.Incentives to reduce avoidable hospital readmissionsfor Medicare patients have decreased the 30-day read-mission rate nationally. Since Medicare payments tothe lowest-performing hospitals were reduced in 2012,hospital-acquired conditions decreased by 17% over a3-year period. Although healthcare spending followingACA implementation has slowed, data through July 2016showed that national healthcare spending had increased4.9%inthepreviousyear(Mossialosetal.,2017).
EVIDENCE EXAMPLE 7.6Impact of ACA on PHN Daily Work
Edmonds, Campbell, and Guilder (2016) surveyed 1,143PHNsacrosstheUnitedStatesontheirknowledge,percep-tions,and practicesunder theACA.Forty-fivepercentofPHNsreportedtheirworkchangeddueto theACA.PHNactivities related to ACA provisions included: integrationof primary care and public health, provision of clinicalpreventive services, care coordination, client navigation,establishing private-public partnerships, implementationofpopulationhealthstrategiesandpopulationhealthdataassessment and analysis, community health assessment,involvement with medical homes and Accountable CareOrganizations,andmaternalandchildhealthhomevisitingservices.
EVIDENCE EXAMPLE 7.7Comparison of U.S. Healthcare System With Other High-Income Countries
TheUnitedStateshasworsehealthoutcomesandhighercarecostsincomparisonwithtenotherhigh-incomecoun-tries (Australia, Canada, France, Germany, Netherlands,New Zealand, Norway, Sweden, Switzerland, and theUnitedKingdom).TheU.S.:
Outofthe11countries inthestudy,theU.S.wastheonlycountry that did not have universal access to healthcare.Access to primary care in the U.S. is poor, which meansthere is “inadequate prevention and management ofchronic diseases, delayed diagnoses, incomplete adher-encetotreatments,wastefuloveruseofdrugsandtechnol-ogies, and coordination and safety problems” (Schneider,Sarnak,Squires,Shah,&Doty,2017).
IHI emphasizes that all three dimensions need to be addressed simultaneously:
IHI believes that to do this work effectively, it’s important to harness a range of community determi-nants of health, empower individuals and families, substantially broaden the role and impact of primary care and other community based services, and assure a seamless journey through the whole system of care throughout a person’s life (IHI, 2017, para. 5).
FIGURE 7.3 Triple Aim Initiative
Health of aPopulation
161CHAPTER 7 n Competency #5
through presenting data about public health needs and col-laborating with other public health professionals and orga-nizations to make a case for funds needed to implement effective public health programs.
Programs of Local Public Health Departments In larger health departments, you might become more specialized with skills and knowledge for a specific public health program, such as follow-up for clients with tuber-culosis or family-planning clinics. In rural health depart-ments, your skill set and knowledge may have to be broader, because you might work in a variety of programs and set-tings. Although variation exists among programs that LHDs provide, some public health services are provided more frequently, such as immunizations and surveillance and epidemiology for communicable/infectious diseases. In addition, population-focused home visiting programs can be offered that target specific vulnerable or high-risk popu-lations, such as parenting adolescents.
LHDs have numerous responsibilities and activities; percentages of the occurrence of specific activities in local health departments are the following (NACCHO, 2016):n Communicable disease surveillance (93%)n Adult immunization provision (90%)n Child immunization provision (88%)n Environmental health (85%)n Tuberculosis screening (84%)n Tuberculosis treatment (79%)n Food service establishment inspection (78%)n Food-safety education (77%)n Schools/daycare centers (74%)n Population-based nutrition services (74%)n Maternal and child health (69%)n Women, Infants, and Children (WIC) (66%)n Home visits (60%)n Family planning (53%)
The NACCHO 2016 report showed that emergency pre-paredness has become an important responsibility of public health, with 81% of health departments providing emer-gency preparedness training to staff. Data from this report noted that LHDs provided screening for a number of dis-eases and conditions in addition to tuberculosis, includ-ing high blood pressure, blood lead, diabetes, cancer, and cardiovascular conditions. Additional health services that may be provided by LHDs are prenatal care, well child clin-ics, oral health, home healthcare, primary care, and mental health and substance abuse services.
Increasingly, LHDs are employing informatics special-ists, given the growth in the use of information technology (IT). Information technology use by LHDs has increased in all categories since the 2008 NACCHO report, particularly
Some health policy experts recommend adding a fourth aim (Quadruple Aim), which addresses the goal of improv-ing the work environments for healthcare providers, clini-cians, and staff (Bodenheimer & Sinksy, 2014).
The ACA does address Triple Aim dimensions to some degree. However, given the U.S. political climate, the future of the ACA is uncertain. Differing values and beliefs about the right to healthcare and partisan politics have contrib-uted to the inability of the 2017 Congress to move forward with a clear healthcare agenda.
Understanding Funding Streams in Local Public Health DepartmentsIn your PHN role, you might be called on to contribute to planning and writing grant applications for funds for spe-cific public health programs. Funding for local public health comes from a mix of local, state, and federal funds, fees, and reimbursements. Because there are multiple sources of funding for public health, budgets are complex and vary each fiscal year. Sources of funding include local taxes, Medicaid, Medicare, client fees, Local Public Health Act state funds, federal Temporary Assistance for Needy Fami-lies (TANF), and private insurance (Riley, Gearin, Parrotta, Briggs, & Gyllstrom, 2013).
Public health programs and funding sources vary across states. For example, in Minnesota, for clients receiving Med-icaid (low-income adults, children, pregnant women, and individuals with disabilities), state law authorizes the Pre-paid Medical Assistance Program (PMAP). This program provides managed care, which includes regular preventive services and illness care, and may include dental care, free car seats, disease management programs for members with chronic conditions, and smoking cessation programs.
Categorical grants are a potential source of funding for local public health programs. Categorical grants, awarded by federal and state governments, are competitive, may have specific eligibility criteria, and are often project-oriented. An example is the Maternal and Child Health Block Grant Program (Title V), the nation’s oldest federal-state partner-ship, which aims to improve the health and well-being of women and children. Funds are distributed to states (who distribute to local health departments) based on a formula and require a match; every 4 dollars of federal Title V money received must be matched by at least 3 dollars of state or local money.
Funding sources often respond to current crises, such as bioterrorism and opioid overdosing. Public health funding is dependent on a flourishing economy; a downturn in the economy means that public health resources might be more limited. Research studies show that there is strong relation-ship between local public health spending and performance of public health departments (MDH, 2012). PHNs have an important role to play in advocating for population health
162 PART II n Entry-Level Population-Based Public Health Nursing Competencies
that assist in working on and achieving public health goals. Nonprofit organizations provide services that contribute to the well-being of persons, communities, or society and do not aim to make a profit. They might be funded by grants or donations and sometimes receive funds from governmental organizations.
Dan notes that nurses from the Medical Reserve Corps are volunteering to help staff some of the immunization clinics. He asks one of the nurses, Grace, how she became involved in the Medical Reserve Corps. Grace comments, “I have a regular job at the hospital in my community, but when I heard about the Medical Reserve Corps, I decided I wanted to help my community if a disaster occurred. I am a volun-teer. I found out about this organization when some of my friends went to New Orleans to help with health needs after Hurricane Katrina.”
Dan later speaks with his supervisor, Carol, about the Medical Reserve Corps.* Carol says, “Since Hurricane Katrina, many healthcare workers in our state have signed up to be in the program, and now it includes more than 7,000 volunteers. This program strengthens the public health response, which we call public health infrastructure, when a disaster occurs. Local coordinators oversee the pro-gram and provide training and support so that volunteers are ready to respond to the disaster. Our health commis-sioner can mobilize volunteers when they are needed.”
Dan responds, “The Medical Reserve Corps is a great community resource. I am going to tell my friends from my last job at the hospital about this wonderful volunteer opportunity.”*NACCHO, 2017
Ethical ApplicationPHNs might encounter an ethical problem regarding immunizations for children if parents are concerned that immunizations can cause their children harm (for example, the worry about the measles vaccination causing autism). An important role for PHNs is to know about evidence on the effects of immunizations to communicate to parents. (See Table 7.10 for the application of ethical perspectives to immunization.)
for the use of electronic records. The NACCHO 2016 report identified the following uses of IT in local health departments:n Have electronic immunization registries (85%)n Electronic disease reporting systems (79%)n LHD website 78%n Use Facebook (65%)n Have electronic health records (EHRs) or plan to
implement EHRs (37%) n Use Twitter (25%)
Community ResourcesPHNs are expected to have knowledge about the many resources that are available to individuals, families, and communities and the referral process needed to receive ser-vices from those resources. LHDs cannot carry out their mission without community partnerships and resources. PHNs build cooperative partnerships with community agencies, organizations, other professionals, and commu-nity groups to respond to community health concerns. (See Chapter 8.) Many nonprofit organizations are vital partners
EVIDENCE EXAMPLE 7.8Community Resources
163CHAPTER 7 n Competency #5
TABLE 7.10 Ethical Action in Providing Immunizations to Children
Ethical Perspective Application
Rule ethics (principles) n Promote justice by providing access to immunizations for families with children, which is consistent with school-entry laws.
n Prevent harm to the children by promoting immunization for this population.n Use evidence about the effectiveness of immunizations and debunk misinformation to provide
education about benefits.
Virtue ethics (character) n Respect individual parental rights to refuse immunization for their children per the law, which allows parental exemption based on religious or other values.
Feminist ethics ( reducing oppression)
n Be aware of using authority in a manner that oppresses parents.n Encourage parents’ voices and perspectives in making decisions about what to do.
n The U.S. healthcare system has poorer healthcare out-comes in comparison to other high-income countries.
n The Triple Aim Framework—which focuses on improv-ing the patient care experience, improving population health, and reducing healthcare costs—is an innovative approach for guiding strategies to improve health sys-tem performance.
n Funding for public health comes from public and pri-vate sources and determines the programs and services that local public health departments can provide.
n Local public health departments work with non-profit organizations to improve the health status of populations.
n All levels of government (local, state, and federal) have responsibility for promoting public health and often work together.
n Three core functions of public health and ten essen-tial services determine the goals of public health departments.
n PHNs who are employed by governmental agencies are responsible for upholding specific laws that protect the public health.
n The public health model focuses on populations and prevention, in contrast to the medical model, which focuses on individuals and provides healthcare services in response to illness and injury.
Governmental organizations develop and enforce laws and regulations to prevent disease and promote the health of pop-ulations. They also provide the resources needed to improve public health. These resources include staff members with expert knowledge and funds to support public health pro-grams and services. As a PHN working for a governmental organization, it is both a responsibility and an honor to con-tribute to improved population health through one’s expert knowledge and skills. Consider how PHNs use their expert knowledge and skills in governmental responses to natural disasters and severe weather.
Locate your state health department web page on emer-gency preparedness for natural disasters. Select a natural
disaster that may potentially impact the health of the popu-lation. Consider how PHNs are involved in helping commu-nities respond to a natural disaster.
n What are the responsibilities of the local, state, and fed-eral levels of government in responding to the disaster?
n How could community resources be involved in responding to the consequences of the disaster (disease prevention and health promotion)?
n How would PHN actions in response to the disaster be consistent with the Cornerstones of Public Health Nursing? (See Chapter 1.)
164 PART II n Entry-Level Population-Based Public Health Nursing Competencies
Healthy People 2020. (2017b). Public health infrastructure. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/public-health-infrastructure
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APPLICATION OF EVIDENCE
1. Which essential services would be most relevant in responding to the natural disaster of flooding in a community?
2. Give a practice example that illustrates each of the three core functions for responding to a flood in a community.
3. Refer to Table 7.7, which identifies the ANA Standards of Professional Performance for Public Health Nursing. How do the following standards apply to the example of a flooding disaster: education, collaboration, resource utilization, leadership, and advocacy?
4. Which public health laws and legal issues do PHNs need to keep in mind when responding to a flood disaster?
165CHAPTER 7 n Competency #5
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