NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

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NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

Our health care advocates help employees navigate the health care system and become better, more informed consumers. We assist employees and their family members with questions about their health care coverage as well as flexible spending accounts (FSAs), health reimbursement accounts (HRAs) and health savings accounts (HSAs).

The responsibilities of community health nurses are vast. They educate residents through health expos and community classes. They go to patients’ homes, community centers, hospice facilities and to long-term care facilities. They also fulfill roles such as a home care nurse or visiting nurse, public health nurse, hospice nurses, school nurse, community advocate and parish nurse.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

These nurses can be found working in agencies like the American Red Cross, Women, Infant, and Children (WIC) and in Nurse Family Partnerships to name just a few. The common thread with all of the different community nurse positions is that they help the public improve their health and maintain healthy lifestyles. They can help prevent hospitalizations through support and education and also assist patients’ transition home from a hospital stay.

 

 

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These nurses are the backbone of healthy communities. Community health nurses assist everyone in the nation, from the youngest to the oldest, and everyone in between.

Another important role of these nurses is emergency preparedness. In 2002, the Public Health Security and Bioterrorism Response Act expanded the expectations of community health nurses so that they could also take on responsibilities of first responders. In the event of a community health crisis, nurses with this specialty would be among the first to respond, develop a plan of action and provide immediate care. Now, in many colleges and schools of nursing, emergency preparedness training is part of the curriculum.

We have healthier communities today because of the tireless efforts of these nurses. Nursing is not a job – it’s a calling. Community health nursing is one very rewarding way for us to be called to serve.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

We make sure your insurance is working the way it’s meant to and that your employees are engaged. Access to knowledgeable and experienced advocates who can help employees shop for their health care, answer benefit questions, locate in-network providers, and resolve claims issues helps employees make better decisions about their care and enables employers to reduce administrative and health care costs.

Employees can’t be true health care consumers if they don’t know how to “shop” for health care. Our advocates provide employees with up to three options for a medical test or procedure, along with quality and cost data, enabling them to make informed decisions about where to find cost-effective care. Armed with this critical information employees, on average, save $400 out-of-pocket per request and employers save more than $1,400 per request.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

The U.S. spends more on healthcare, yet has a lower life expectancy and worse health outcomes, than any other high-income nation according to a 2015 study from the Commonwealth Fund.

Global health issues (GHIs) require global cooperation in response, planning, prevention, preparedness, and care that reflects health equity issues among nations. These issues require complex interprofessional and interagency cooperation and solutions that involve governments, non-profits, and many times include private companies and foundations. More than ever, the response to GHIs requires a broader understanding of how connected we are in today’s world. This article considers response to issues of emerging infectious diseases, human trafficking, maternal-newborn health; preparedness for health inequities within a framework of social justice, equity; and mal-distribution of health workers globally. We define and describe emerging global health issues from a nursing perspective and offer a call to action for nurses to increase awareness as global leaders.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

Hospitals are taking a stance on patients’ lifestyles since non-medical factors such as social, behavioral and environmental issues have a substantial impact on patient health.

Tech companies have also been stepping into the population health ring. In March 2018, Uber announced Uber Health: a way to partner with healthcare organizations to provide reliable, comfortable transportation for patients. The announcement mentioned that over 100 U.S. healthcare organizations, are already using Uber Health to encourage patients to be more proactive in their care.

As more organizations focus on population health initiatives, healthcare workers adjust their practice to fit those needs. The role of the bedside nurse continues to shift beyond acute care.

Promoting wellness and disease prevention is not new to nurses at the bedside. However, since the Affordable Care Act in 2010, more reimbursement programs are encouraging hospitals to be catalysts in community health engagement. Many U.S. facilities require nurses to be patient health advocates in helping people stay healthy and avoid chronic diseases.

In 2016, the National Advisory Council on Nurse Education and Practice (NACNEP) called for changes in nursing education to better align with a new emphasis away from acute care and toward population health management.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

Population health management programs are geared toward closing the gap of health disparities across demographics because of social determinants of health. Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks, according to Healthy People 2020.

In 2016, the Centers for Medicare and Medicaid Services announced a 5-year, $157 million test of a payment model called Accountable Health Communities to accelerate the development of a scalable delivery model for addressing upstream determinants of health. Hospitals in lower-income areas have more pressure from Medicaid to enact population health management initiatives. The impact of population health programs is much greater in lower-income urban communities than in suburban counterparts. NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

According to the 2015 study Moving From Patient Care to Population Health: A New Competency for the Executive Nurse Leader, the goal in population health management is to keep the patient population as healthy as possible and minimize the need for acute care interventions such as emergency room visits and hospitalizations. If population health initiatives are measured successfully in terms of a reduction in the total cost to the organization, hospitals are rewarded with increased reimbursements.

Why the disparity? Other countries have been doing something the U.S. has not—applying public health concepts to chronic disease management. The economic models of countries such as France, Germany, and Norway align with controlling costs while producing better outcomes. As an illustration, private healthcare spending in the U.S. is five times that of the second-highest spending country (Canada). And despite this astronomical private spend, the U.S. is also third-highest in public spending, despite only covering 34 percent of residents through public programs including Medicare and Medicaid.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

The higher costs in the U.S. are not producing better outcomes. Of the countries covered in the Commonwealth study, the U.S. had the lowest life expectancy at birth—78.8 years. And it performs equally poorly for chronic conditions such as diabetes (third-highest rate for lower extremity amputations as a result of diabetes) and ischemic heart disease (highest mortality rate).

The purpose of this study is to identify and analyze factors that affect the ability of public health nurse (PHN) leaders to influence public health policy development. Longest’s model of public policymaking provided the theoretical framework. Eight PHN leaders representing rural, suburban, and urban population areas participated in semistructured interviews. Findings suggested factors that affect the PHN leaders’ abilities to influence public health policy development: existing barriers such as political factors, gender issues, a lack of public understanding, financial issues, and resource limitations; skills training in policy development; academic preparation; political competency; political power associated with policy development responsibilities; leadership competency; and the ability to use research to influence policy making. Recommendations include strengthening academic preparation in policy development and creating support for growth in leadership competency, political competency, and research skills for current PHN leaders.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

 The focus of this course is on application of theories and concepts from nursing and public health sciences in assessing health status, preventing and controlling disease, and promoting a healthier population by working with families, aggregates, communities, and healthcare systems. Students apply system thinking by using epidemiological and community assessment techniques to examine  at-risk populations, health promotion, and levels of prevention with special emphasis on ethnically diverse and vulnerable populations. Major local, state, and national health issues are considered including, communicable disease, chronic illness, environmental and occupational health, bioterrorism, emergency and disaster preparedness and response. Practice experiences provide learning experiences in population-based health promotion by collaborating with interdisciplinary public health partners in a local community. 
 

 

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As life expectancy in the United States is declining and the number of people struggling with chronic conditions continues to rise, nurses are everywhere: in our hospitals, schools, businesses, homes, and communities.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

There are many social, political, and economic influences shaping healthcare delivery today that are expanding the scope of responsibility for the executive nurse leader. The focal point of change is the passing of the Patient Protection and Affordability Care Act (ACA), where there is a clear strategic shift to provide patient care in the right setting with the formation of Accountable Care Organizations (ACOs). Financial reimbursement strategies are being aligned to facilitate these changes. Executive nurse leaders are trying to navigate through these healthcare changes by developing cost-effective care delivery models, supporting the role of the professional and advanced practice nurse, and advocating for the patient. In healthcare reform, this translates to healthcare being delivered in community venues and the executive nurse leader being the advocate for the healthcare needs of the population in the community.

Consistently named as the most trusted health profession, nurses are trained to see each person they care for in the context of his or her life. Regardless of their specific backgrounds or assignments, nurses have a responsibility and obligation to promote public and population health no matter where or how they practice. To truly achieve the best possible health and well-being for everyone in our nation, it is increasingly essential for nurses to play an expanded role.

Stemming from a range of Robert Wood Johnson Foundation (RWJF) programs focused on the nursing profession, this collection includes analysis and perspectives how to more fully leverage nurses in addressing critical public health issues aross our nation, and incorporate a stronger population health focus into nursing education and practice.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

With the advent of preventive health care, a moral tension arose between giving resources to the needy, and teaching them how to meet their own needs. Nursing of the acutely ill fits more easily into a model of one-way flow of resources from nurse to patient (Buhler-Wilkerson, 1989). The new public health nursing role struggled, and continues to struggle, with appropriate interventions that would achieve quick results, but also leave lasting improvements in the population. The Christian principle of helping those who help themselves guided this tension, but could not easily resolve it (Brainard, 1922, 1985). Public health nurses were urged to balance “wisdom and kindness” (Buhler-Wilkerson, 1989, p.32). Giving free services or free supplies to the poor was seen as creating dependency and upsetting the natural social fabric of communities. Public health nurses have addressed this moral tension over many years with innovative solutions that seek positive health outcomes, as well as advocate for vulnerable populations.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

By the early 1900s, public health nursing roles extended beyond the care of the sick to encompass advocacy, community organizing, health education, and political reform (American Nurses Association [ANA], 2007). Several examples of exceptional PHN initiatives show how these roles improved the health of communities and populations. The visionary work of Lillian Wald’s Henry Street Settlement, started in New York City in 1906, evolved from finding and caring for the sick poor, to advocating and educating about the poor to other organizations. Wald expanded this mission to advocating for new federal agencies and a host of local improvements (Stanhope & Lancaster, 2011).NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

In the 1920s in Mississippi, Mary Osborne formed a collaborative between public health nurses and African-American (AA) lay midwives to improve perinatal mortality of AA women and babies (Lundy & Bender, 2001). In the 1960s in Detroit, Nancy Milio integrated community organizing, community decision-making, and PHN to develop a maternal-child health center that was highly accepted and even protected by the AA neighborhood during the “Detroit riots” (Milio, 1970). Public health nurses and other community professionals have continued to recognize the advantages of community participatory methods, including the potential for more effective intervention outcomes and capacity-building for long term benefit to the community (Savage et al., 2006).NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

The community participation and ethnographic model (see Figure 1) is an innovative framework that demonstrates evolving public health nursing practice. It was developed, based on the work of Aronson, Wallis, O’Campo, Whitehead, and Schafer (2007a), by an inter-professional research team from the University of Virginia (UVA), Virginia Polytechnic Institute and State University (Virginia Tech [VT]), and Carilion Clinic (CC) (Kulbok, Meszaros, Bond, Botchwey, & Hinton, 2009) to address youth substance use prevention in a rural tobacco-growing county of Virginia. The community participation and ethnographic model builds on assumptions underlying community-based participatory research (CBPR) and encourages engagement of community members and trusted community leaders in processes from problem identification to project evaluation and dissemination. The CBPR approach is philosophically based in critical and social action theory; it builds partnerships with community members across social-economic status and focuses on community assets and resources rather than on deficits (Israel, Eng, Schulz, & Parker, 2005; Kretzmann & McKnight, 1997). CBPR seeks balance between community members and practitioners or researchers through shared leadership, co-teaching, and co-learning opportunities; it benefits from the expertise of both community members and practitioners or researchers NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

At an advanced level, PHN knowledge and competencies prepare nurses to take a leadership role to assess assets and needs of communities and populations and to propose solutions in partnership. Community- or population-focused solutions can have widespread influence on health and illness patterns of multiple levels of clients including individuals, families, groups, neighborhoods, communities, and the broader population (ACHNE, 2003).

The purpose of this article is to describe evolving roles in the specialty of public health nursing. A brief history of PHN provides a historical and philosophical background for current practice. A model for community participation with ethnographic orientation, and an exemplar of its use in a rural youth substance use prevention project, illustrates current advanced PHN practice. The article concludes with a discussion of essential PHN competencies, evidence that supports evolving PHN roles, and implications for contemporary public health nursing roles.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

Prevention and curative care have been distinct concepts since ancient times. In Greek mythology, Hygeia was the goddess of preventive health, and her sister Panacea was the goddess of healing (Lundy & Bender, 2001). The notion of health care as healing, or treating those already sick, maintained dominance over preventive care for many centuries. During the mid-19th century however, new scientific understanding of transmission of disease enabled successful sanitation interventions that prevented disease on a large scale.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

To carry preventive care forward, district nursing evolved as the first role for public health nurses, and Florence Nightingale concurrently professionalized nursing as an occupation (Brainard, 1922, 1985). Evolving PHN practice required an understanding of how culture, economics, politics, psychosocial problems, and sanitation influenced health and illness and the lives of patients and families (Fitzpatrick, 1975). Public health nursing in the United States (U.S.), England, and other countries quickly grew to include working with vulnerable populations in diverse settings including communities, homes, schools, neighborhoods, and worksites.

If patient-centered or patient-first medicine is the new paradigm toward wellness, prevention and improved outcomes – and I strongly believe it is – then how do we really get there?NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

 

The pressures include keeping providers at the top of their license while still developing a more holistic relationship with patients that can expand into team-based case management. And patients with chronic conditions may have several providers prescribing care.

 

The nexus point is gauging patient willingness – and ability – to comply with “doctor’s orders” to a level where case management meets self-management, and to a level where case management rises beyond decreasing readmissions or ED visits.

Social determinants of health are are showing us just how unique each patient’s story is outside of the hospital or the office visit.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

 

Part of the answer is for health systems to understand the community services available and make solid connections with those agencies. That’s an aspect of case management systems often struggle with in a competitive environment. Hospitals, for example, are dutifully posting Community Health Assessments, but this shouldn’t be done in isolation or approached as a checklist process.

In 2016, the National Advisory Council on Nurse Education and Practice (NACNEP) called for changes in nursing education to better align with a new emphasis away from acute care and toward population health management.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

Before exploring what that means for the nearly 3 million nurses in the United States, it is worth taking a moment to examine the relatively new concept of population health.

A standard definition of population health emerged from a 2003 report published in the American Journal of Public Health entitled, What is Population Health? In the report, authors David Kindig and Greg Stoddart defined population health as: “Health outcomes of a group of individuals, including the distribution of such outcomes within the group.”

This was the definition used by the NACNEP in its 2016 report, “Preparing Nurses for New Roles in Population Health Management.” While it has become the accepted definition of the term, the concept continues to evolve as the role of healthcare professionals is refined.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

In 2015, the online publication Healthcare IT Newssought clarity by asking 37 healthcare leaders to offer their personal definitions of population health. The definitions varied, but a consensus emerged around opportunities for health systems, agencies and organizations to work together for better health outcomes in their respective communities.

And that is where the idea of population health begins to be revealed as a practical concept for understanding and meeting the needs of patient communities throughout the nation.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

The concept of population health represents a cycle that begins with the vast amount of health data that has become more accessible through electronic health records. That information is analyzed to develop risk assessment models for specific groups of people.

The risk assessment analyses are used to develop prevention techniques, and to determine best practices for treatment. The health outcomes that are derived from the prevention and treatment methods are then researched and combined with the existing data, which allows healthcare professionals to refine prevention and treatment techniques based on the improved data.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

A number of questions arise along the way. According to Healthcare IT News, one of the most pressing questions is, “What is more relevant in the health outcomes of a population set, the behavior of its members or the actions of the healthcare provider?”

The answer to that question is being formulated even now as healthcare workers, especially those on the front line of care – nurses – are implementing population health management concepts into their approach to patient care.

According to the NACNEP report, the “jobs of many nurses are changing dramatically in the evolving healthcare system.” This is not news to nurses, whose responsibilities in recent years have increased and shifted in hospitals and other ambulatory care settings, as well as in research labs around the world.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

This expansion and evolution of nursing responsibility, coupled with the fact that nurses represent the largest group of healthcare providers in the U.S., gives the nursing profession a tremendous amount of influence when it comes to the shift from a system that focuses on acute care to a system guided by the principles of population health.

Nurses are uniquely positioned to lead the effort to adapt the healthcare system to the changing needs of the many population groups in the U.S. According to the NACNEP report, nurses can:NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

  • Discover patterns across patient populations
  • Guide patients toward community resources and social services
  • Lead in the development of broad-based treatment and prevention methods

The NACNEP report further recommends a number of improvements to nursing curriculum in order to meet the requirements of a focus on population health. Nurse education, then, should enable nurses to:

  • Undertake population health initiatives
  • Support complex patient groups
  • Provide care coordination
  • Analyze population-level data from electronic health records and other sources
  • Optimize the use of research to promote evidence-based care NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

Much of the movement toward a population health model involves the use of digitally stored data becoming available with the shift from legacy record-keeping methods to electronic records.

It’s become widely accepted that episodic healthcare visits have less to do with overall health and wellness then behavior, genetics and socioeconomics. As far back as 2007, a New England Journal of Medicine article put the impact of direct healthcare at around 12 percent.1

I certainly believe that social determinants of health data needs to be factored into analytics and risk, but I fear again a checklist approach that will expand patient data, but the question is what do you do with that data? And how do you factor that data into wider population health management?NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

 

I wonder about this as vendors develop these data platforms and organizations such as the American Academy of Family Physicians and CMS, both in 2018, produced detailed SDoH screening tools. These is all good steps, but then how do we make the data actionable?

In terms of population health management, can we use the data to find common SDoH issues that impact many patients, and find best practices to counter? One example is data from HHS’ Agency for Health Research and Quality, which found as far back as 2013 that malnutrition is a factor in 12 percent of non-maternal, non-neonatal hospital stays, accounting for $42 billion in annual healthcare spending. Is it avoidable, and how can a primary care team bridge community services to avoid these hospitalizations and costs?NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

Every healthcare organization – health plans, hospitals, physician practices, even employers – is in the process of transitioning to value-based care and alternative reimbursement models.

And that means you need tools to support a new way of working – tools that allow you to better manage and improve population health and control cost. To be effective, your organization must know how to easily identify, monitor and engage different groups of patients, including:NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

  • the healthy
  • the chronically ill
  • the catastrophically ill, and
  • especially those patients with emerging or rising risk.

That’s precisely what we help our clients do. Our proven results and client success stories show how we’re driving collaboration between healthcare providers, health plans and employers, and effectively simplifying the evolution to value-based care.

A Chicago-based ACO much more recently began screening high-risk patients for malnutrition, and offering post-discharge follow ups such as community referrals and nutrition coupons. The ACO reports savings of more than $3,800 per patient.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

But can acting on SDoH data really become a part of universal workflows and even be a factor in healthcare business models?

 

Medicare Advantage plans, beginning in 2020, are developing some inroads by way of reimbursement fees for transportation, food and levels of in-home support for chronically ill patients. That’s a big step, in line with last year’s policy goals statement by HHS that broad SDoH payment models are being looked at.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

 

These points of tangibility can take social determinants out of the abstract as just another data point and advance case management to the community level, and at the same time hopefully derail the notion that SDoH only impacts Medicaid-level or poor patients. We all have habits and markers.

 

What’s even more encouraging big picture is a January, 2019 report in the peer journal Academic Medicine that published a consensus call to build clinical approaches to social determinants into medical school curriculums.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

Thoughtful but impactful steps can mean a lot to patients and providers struggling to find common ground.

Hospitals are taking a stance on patients’ lifestyles since non-medical factors such as social, behavioral and environmental issues have a substantial impact on patient health.

Tech companies have also been stepping into the population health ring. In March 2018, Uber announced Uber Health: a way to partner with healthcare organizations to provide reliable, comfortable transportation for patients. The announcement mentioned that over 100 U.S. healthcare organizations, are already using Uber Health to encourage patients to be more proactive in their care.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

As more organizations focus on population health initiatives, healthcare workers adjust their practice to fit those needs. The role of the bedside nurse continues to shift beyond acute care.

 

 

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Promoting wellness and disease prevention is not new to nurses at the bedside. However, since the Affordable Care Act in 2010, more reimbursement programs are encouraging hospitals to be catalysts in community health engagement. Many U.S. facilities require nurses to be patient health advocates in helping people stay healthy and avoid chronic diseases.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

In 2016, the National Advisory Council on Nurse Education and Practice (NACNEP) called for changes in nursing education to better align with a new emphasis away from acute care and toward population health management.

Population health management programs are geared toward closing the gap of health disparities across demographics because of social determinants of health. Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks, according to Healthy People 2020.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

In 2016, the Centers for Medicare and Medicaid Services announced a 5-year, $157 million test of a payment model called Accountable Health Communities to accelerate the development of a scalable delivery model for addressing upstream determinants of health. Hospitals in lower-income areas have more pressure from Medicaid to enact population health management initiatives. The impact of population health programs is much greater in lower-income urban communities than in suburban counterparts.

According to the 2015 study Moving From Patient Care to Population Health: A New Competency for the Executive Nurse Leader, the goal in population health management is to keep the patient population as healthy as possible and minimize the need for acute care interventions such as emergency room visits and hospitalizations. If population health initiatives are measured successfully in terms of a reduction in the total cost to the organization, hospitals are rewarded with increased reimbursements.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

Common ways that hospitals measure population health management success are as follows:

  • Increased levels of physical activity
  • Declines in newly diagnosed cases of diabetes
  • Fewer work days lost to illness or disability

Nationwide Children’s Hospital in Columbus, OH became a part of an accountable care organization under Medicaid, making the hospital financially responsible for treating sick children. Nurses in the ER were treating a high-volume number of patients with injuries and illnesses related to gang violence and other social issues surrounding the Southern Orchards neighborhood. Financially, the organization was struggling to treat all the patients in the ER, which lead them to address the issue at a community level.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

Nationwide Children’s Hospital began a population health management program in partnership with a network of faith-based and community development organizations, youth-serving nonprofits and local public schools in 2009. Over the next nine years the hospital tracked the results of their program.

Tackling employment and housing issues first, the hospital hired 800 residents from the surrounding neighborhood and renovated several buildings into affordable housing units. Since the initiative, the hospital’s insurance company reports indicate that emergency room use has declined compared to use by kids from nearby neighborhoods. The homicide rate declined, and no homicides occurred in the neighborhood in 2017. NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

Every population health management program success factor will vary based on the community’s needs. Nurse professionals are at the front line of these initiatives, and the success of the program will rely heavily on their efforts.

In the health care system, nurses are the primary contact for patients. Nurses see, firsthand, the emerging patterns across patient demographics and identify the need to address wide-ranged treatment and preventative measures. With such insight, nurses have the ability to spearhead population health initiatives through patient empowerment.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

Nurses have the opportunity to establish a strong relationship with their patients by engaging them in their care. Promoting patient participation can reduce recovery time, future injury, and readmissions to the emergency room.

Healthcare professionals have indicated that introducing patient participation in a model of care can be difficult. NEJM Catalyst’s latest Insights Council survey on patient engagement found that 63% of respondents said that the time investment required by healthcare professionals is the biggest challenge in implementing patient engagement into care delivery.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

Understaffing has a major impact on the lack of patient engagement. Without proper patient ratios, nurses don’t have enough time to connect with patients, and the effects of nurse burnout can negatively impact the patient experience.

Beyond staffing challenges, Bertrand Ross, MD, FACC, FACP, Medical Director at Virginia-based Optima Health, said that another problem with patient engagement is that incentives are not aligned. The time and effort to educate, motivate, and troubleshoot issues regarding patient engagement are not restituted very well at present. Creating alignment and increasing staff levels will remove that time investment challenge.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

Despite the challenges that patient engagement presents, nurses can overcome some of those issues in three critical areas to address population health management:

  • Strong patient communication
  • Education
  • Diversity inclusion

It’s essential for a nurse to build a strong and trusting relationship with a patient to keep a patient engaged. Nurses need to practice transparency in communication and open that door for patients to feel safe in taking ownership of their health beyond the hospital walls. It starts with trusting the nurse.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

Some hospitals require nurses to ask patients to read back their bedside shift reports as a form of education and patient engagement. Asking a patient to be involved in that process shows strong customer service, she says, it makes the patient feel valued and cared for.

The importance of patient participation remains the force behind the success of population health management programs. The extent to which, and in what ways, patients want to and are able to contribute remains complicated and multifaceted.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

Nurses remain the leaders in population health initiatives. Their leadership in patient engagement and treatment education is required to reduce injuries and illnesses within people population groups. It’s important that nurses feel empowered as leaders to take on that role.

The nurse shortage has added stress on facilities to meet the basic patient care requirements. Committing to patient engagement is a challenge for many facilities facing the nurse shortage and higher patient demand. Finding innovative solutions to the nurse shortage to increase nurse staffing levels is critical in successfully implementing patient engagement initiatives  NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

Nurses can play an integral part in population health, but leadership and technology training needs to be a larger part of nurse training. That’s according to a Robert Wood Johnson Foundation (RWJF) study released in September 2017.

The report finds that public health nursing at local and state agencies, in community and ambulatory settings, and in schools will continue to grow as population health strategies help identify where the biggest healthcare gaps exist.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

Many population health strategies include looking at patients holistically, including social, economic, and cultural determinants, and nurses are already trained in those areas to deliver patient care, according to the study.

Paul Kuehnert, DNP, RN, FAAN, assistant vice president for RWJF Program staff,NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

“Nurses are trained to think holistically, to consider the context of a patient’s life and how that impacts his or her health,” says Paul Kuehnert, DNP, RN, FAAN, assistant vice president for RWJF Program staff,  who commissioned the study. Whole care also means assessments of the patient’s healthcare environment, which can include acute, ambulatory, home, behavioral health and community interventions. “Because of the nature of their roles, nurses often spend more face-to-face time with patients, which allows them to gain insight into the community and societal factors that impact patients’ lives and health. Armed with this insight, nurses can work with primary care physicians to help connect patients to resources within the community that can improve their overall well-being.”NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

How to better utilize nurses

1.      Encourage collaboration and dialogue

Unfortunately, nurses aren’t trained for leadership positions and are rarely a part of population health strategy development, the study finds. Kuehnert says that scope of practice regulations that vary based on the state, often restrict nurses’ time and ability to expand their roles.

“Culturally and historically, nurses—unless they hold formal leadership roles—tend not to view themselves as leaders. Nurses must understand, internalize, and act on the knowledge that nurses can be and are leaders, irrespective of their titles—and that by collaborating with policymakers, businesses, health systems, and more, nurses can exponentially increase the impact they have, well beyond the healthcare setting,” Kuehnert says.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

2.      Help them use data to focus efforts

Increasing nurses’ capacity to make data-driven decisions is another part of the future of population health nursing. According to the study, nurse care coordination for low-risk patients that utilize healthcare services the most has been found to be the most cost-effective way to improve outcomes. Of all patients with high healthcare utilization, 60% to 75% can be classified as low-risk populations.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

“We’ll also need to better prepare nurses for key evolving population-focused nursing roles in fields that include care management, chronic disease management, and population data analysis. These roles require core clinical knowledge and understanding combined with skills and abilities to identify and evaluate community resources, make and track referrals to community-based services, and measure outcomes,” Kuehnert says.

3.      Increase their technology literacy

Rapid advancements in telehealth, EHRs and mobile devices are a part of clinical care, prevention, and health communications that will continue to integrate into daily use for clinicians.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

“Education should provide students with the technical skills they need to compile and analyze population and community data in order to understand the impact of the community conditions on patients’ health,” Kuehnert says. “And how they, as nurses, can influence change within their communities to improve health.”

Kuehnert says the insights nurses gain about patients’ life circumstances need to be systematically shared to inform care by the entire multidisciplinary team.

“We need to share bright spots of nursing leadership for population health improvement and spread them widely,” he says. “Widespread adoption of population-focused nursing practice will likely take place over the next five to 10 years as mindsets and expectations shift in nursing and healthcare.”NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

Nurses in community health work with people from many different cultural backgrounds, often with disadvantaged and marginalised people.

In partnership with their local communities, nurses in community health work to prevent illness and promote health across the lifespan by identifying barriers to healthy lifestyles and general wellness. They work with families and communities to empower individuals accessing care to change unhealthy lifestyles and provide post-acute care to people in their homes.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

It is important that a nurse considering working in community health, is able to assume responsibility and a leadership role, take initiative in emergencies, have strong communication skills, can work autonomously and as part of a team, maintains patience and discretion when providing health care, and is open to working both in a clinical setting and off-site, such as conducting home visits.

Nurses in community health provide an interpretative bridge between the acute sector and community services. They embrace a social model of health to advocate and give a voice to the community accessing care. In a system which is often complex and hard to navigate, nurses in community health are able to simplify the health systems, referral pathways and access to care.NURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

Nurses in community health work in an interdisciplinary team which can include, but is not limited to, mental health nurses, podiatrists, general practitioners, psychologists, women’s health nurses, Aboriginal health workers, allied health and hospital services.

As a nurse working in community health, membership with APNA can support you to keep up to date with industry news, connect you to other nurses in community health care, advance your knowledge in areas relevant to primary health care, safeguard your registration with quality and cost-effective professional indemnity insurance, and make informed career and professional decisions with access to the member-only Nurse Support Line. mNURS 4210 – Role of the Nurse Leader in Population Health Essay Paper

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