Let s begin by discussing the definitions, statutory references, and theoretical models that describe the PHN role.

Transcription

1 I m Jody Moesch Ebeling, one of the Northeastern Regional Public Health Nursing Consultants. Welcome to the Public Health Nurse Orientation Module 3, Services to Prevent Chronic Diseases and Injuries. This module was written by Deborah Pasha, the Southeastern Region Public Health Nursing Consultant and myself in consultation with the other Regional Nursing Consultants and others from the WI Division of Public Health. Deborah Pasha and I will present this module together. 1

2 This module provides a background for understanding the public health nursing role in disease and injury prevention for families and communities. Required services to prevent chronic diseases and injuries as set forth in state statute and administrative rule will be discussed. In this module, you will find: Definitions, statutory references, and theoretical models describing the PHN role; Conceptual framework of the community-as-client; Resources, including credible references and funding and Application examples 2

3 Let s begin by discussing the definitions, statutory references, and theoretical models that describe the PHN role. One of the five required services of a local health department is to provide services to prevent other diseases. In this module, we will explore how the services are provided or assured by the local health department. We will identify how the Wisconsin statutes relate to the prevention of diseases, the resources available, including state and regional consultants, some of the public health interventions that are applied to disease prevention, and what is your, the public health nurse, role in this mandated service. Other disease prevention means programs and services that reduce the risk of disease, disability, injury or premature death caused by such factors, poor health practices or environmental agents of disease (HFS ). Other diseases refer to chronic conditions, diseases and injuries which may include cardiovascular disease, diabetes, and other special health care needs experienced by children and adults. By implementing and addressing health promotion or healthy lifestyle choices we can in part decrease the incidence of chronic disease, injury or the progression of disease. However, of equal or more importance is the leadership role that public health professionals contribute in working with other public health system partners, to assure and to provide healthier and safer environments in which individuals can live more productive lives. 3

4 The public health nurse has a vital role taking action to prevent disease. Public health nursing interventions include development of evidence-based policies, procedures, and guidelines to assure consistent action with the community partners to prevent these diseases. Here are some common terms that are used in disease prevention. If you d like a refresher, refer to the website and link to Wisconsin Statutes Chapter (1) and Wisconsin Administrative Rule HFS

5 How do we prevent chronic diseases and injury? Administrative Rule HFS provides guidance for public health nurses. This includes informing the public about the occurrence of diseases and injury in the community, disseminating prevention guidance, and arranging programs to address priority problems. In the upcoming slides we will examine the role of the public health nurse for each of these four statutory requirements. According to statute, Wisconsin local health departments are responsible to: Inform local elected officials, public health system partners, and the general public about the occurrence and underlying causes of priority problems and emerging conditions, illnesses, injuries, and events affecting the health of the population. The public health nurse provides and explains data to these public health system partners. Epidemiologists are expert resources for data assessment and presentation. Accurate information is critical for decisions about the use of resources and for policy development. 5

6 Remember the Public Health Interventions Wheel model? You ve seen this model in the previous PHN orientation modules. The 18 interventions are divided into 5 wedges. For more details regarding this model, please refer to materials available from the Minnesota Department of Health. The interventions in each wedge are related to each other in that they are frequently implemented in conjunction with one another. However to prevent chronic diseases, you will find that you simultaneously utilize interventions throughout the wheel. We ll see how this happens by considering which interventions might be used to address this statutory required service, and then later look at a few specific examples. What is the role of the public health nurse? At least 3 interventions from the wheel are operating at the same time: Surveillance, which describes and monitors health events through ongoing and systematic collection, analysis, and interpretation of health data for the purpose of planning, implementing and evaluating public health interventions. 6

7 Disease and other health event investigation, which gathers and analyzes data regarding the threats to the health of the population, determines source of threat, identify cases and determines control measures. Collaboration, in which 2 or more persons/organizations commit to achieve a common goal. This is the well-known graphic Epidemiologic Triangle. The AGENT or the What is the cause of the disease or injury. The HOST or the Who are the organisms which have been exposed to or are affected by the disease or injury. And the ENVIRONMENT or the Where is the environment or are the conditions that are outside of the host which cause disease or injury. Therefore, epidemiological assessment of data to identify disease and injury trends are incorporated in the assessment phase of the nursing process. The second service requires the local health department to disseminate prevention guidance related to diseases and injuries, including information about behaviors that reduce the risk of contracting them. Public health professionals implement programs and environmental changes 7

8 for population groups using evidence-based practices and available resources. Public health nurses are integral members of the public health team in implementing this service. What is the role of the public health nurse? At least 2 interventions from the wheel are activated: Outreach locates populations of interest or at risk and provides information about the nature of the concern, what can be done and how services can be obtained. Community organizing helps groups identify common goals, develop and implement strategies for reaching the goals they have collectively set. Third, local health departments arrange screening, referral, and follow-up intervention services for population groups. Public health nurses work with health educators, nutritionists, and private partners to assure the community has sufficient access to quality services. Public health professionals assure the use of evidence-based practices and available resources. 8

9 What is the role of the public health nurse? Wow! To address this service you will use multiple interventions: Case finding occurs at the individual-household level of surveillance, disease and health event investigation, outreach, and screening. Public health nurses locate individuals and connect them to services. Outreach locates at-risk populations and provides information about the nature of the concern, what can be done and how services can be obtained. Screening identifies individuals with unrecognized health risk factors or disease conditions. Delegated functions are tasks carried out under the authority of a health care practitioner as allowed by law. Case management increases individual/family s ability to secure services and the capacity of the community to coordinate/provide services. Referral and follow-up links people to resources. Local health departments implement measures or programs designed to promote behavior that is known to prevent or delay the onset of chronic disease and injuries. 9

10 This would include local or state environmental policy development and implementation to assure access to environments in which people can lead healthier lifestyles. Examples include promoting and/or enforcing child car seat and restraint policy, smoke-free air policy, tobacco sales to minors, and The Essential Diabetes Care Guidelines. What is the role of the public health nurse? Now you will use a combination of at least 4 interventions: Advocacy focuses on developing community, system or individual capacity to plead their own cause or act on their own behalf. Social Marketing utilizes commercial marketing principles to influence the knowledge, attitudes, behaviors and practices of the population of interest. Policy Development results in changes in practices through policies, laws, rules and regulations, ordinances. Enforcement compels others to comply with the laws, rules, regulations. Coalition building promotes and develops alliances among organizations or constituencies for a common purpose. This next section covers the conceptual framework of the community as client. 10

11 The concept of community as client is integral to the discipline of public health nursing practice. In contrast to other nursing disciplines which focus on an individual client and treatment of disease, public health nursing is uniquely concerned with the well-being of the entire community and prevention of disease and injury. (Ervin, Naomi E., Advanced Community Health Nursing Practice/Population-Focused Care Prentice Hall, New Jersey, 2002) The client or unit of care is the population. While the public health nurse may engage in activities with individuals, families, or groups, the dominant responsibility is the population as a whole. Public Health Nursing: Scope & Standards of Practice (ANA, 2007) 11

12 Public health nurses involved in the prevention of diseases and injuries often reference the Social Ecological Model, encompassing the community-as-client. The most effective strategies address all five circles of the model. Go in Search of your people. Love them. Learn from them. Play with them. Serve them. Begin with what they have. Build on what they know. But of the best leader, when the task is accomplished, the work is done, the people will remark We have done it ourselves. - Old Chinese Proverb In other words, public health nurses have the honor of working with the community to assist in the recognition of strengths and in the implementation of solutions. 12

13 Health and illness are influenced by the interaction of multiple factors that include the social and physical environments, individual behavior, access to care and all of the factors pictured here. These factors are known as the Determinants of Health. We have among the worst disease outcomes of any industrialized nation - and the greatest health inequities. It's not just the poor who are sick. Even the middle classes die, on average, almost three years sooner than the rich. At every step down the socio-economic ladder, African Americans, Native Americans and Pacific Islanders often fare worse than their white counterparts. Interestingly, that s not the case for most new groups of immigrants of color. Recent Latino immigrants, for example, though typically poorer than the average American, have better health. But the longer they live here, the more their health advantage erodes. (LARRY ADELMAN Series Executive Producer & Co-Director of California Newsreel, Unnatural Causes, 2008) 13

14 The public health system seeks to extend the benefits of current knowledge in ways that will have maximum impact on the health status of the entire population. It is a collective effort to identify and address the unacceptable realities that result in preventable and avoidable health outcomes. (Turnock, 2001) The Public Health System is best understood as a broad enterprise, anchored in government. It is a partnership for collective action of those who work together toward the attainment of a shared vision of healthy people in healthy Wisconsin communities. (SHP 2010) The public health nurse contributes a unique perspective and approach to finding solutions, utilizing the public health nursing process to evaluate the issues and select community-based interventions cooperatively with other disciplines and agencies. Participatory work with the people and agencies in the community is critical to effective planning similar to the process that evolves in relationship to a single individual client. 14

15 Public health nurse are a flexible entity in an otherwise concrete enterprise. (Quoted from Marla E. Salmon during her tenure with the US Public Health Service). What does this mean? Public health nurses are entrusted to bring their knowledge of science and artfully apply it within the community, in their work with individuals and other agencies and disciplines. In doing so, public health nurses uniquely influence the establishment of mutual goals and priorities, and the dedication of resources to healing the community-client. A local board of health shall assure that measures are taken to provide an environment in which individuals can be healthy (7) Local communities identify residents that are representative of their community, to provide oversight to the local health department. This leadership body is called the board of health. Health department staff, including public health nurses, are responsible for providing information to the board. 15

16 In April 2008, The Governor signed CHIP into law. So let s talk about this in terms of the nursing process. For the community, the assessment component is called a community needs assessment. In order to do this, please refer back to the generalized public health nursing model as presented in HFS 140 and also Module I. Here you find details of the requirement to collect, review and analyze data on your community s health. Following the assessment phase, collaborative public health nursing expertise is provided to identify the community health priorities, goals and objectives to address current and emerging threats to the health of individuals, families, vulnerable population groups and the community as a whole. Prevention and early intervention programs for the population include addressing the underlying determinants of health, and those that are disease or injury specific. There s an evaluation component, too! Local and state partners convene together for the statewide Community Health Improvement Planning process. Vision: A healthy Wisconsin is a place where All residents reach their highest potential; Communities support the physical, emotional, mental, spiritual, and cultural needs of all people; 16

17 People work together to create healthy, sustainable physical and social environments for their own benefit and that of future generations Mission: To protect and promote the health of the people of Wisconsin I m Deborah Pasha, the Southeast Region Public Health Nursing Consultant. I will present section III on resources and funding sources, and section IV covering some application examples. When you assess the strengths of the community-client, you discover resources in the system of partners that are necessary to achieve positive outcomes in health priorities. 17

18 Wisconsin Statutes Chapter 255 outlines the state s requirements to conduct programs that address chronic disease and injury prevention. The Bureau of Community Health Promotion has a primary responsibility to provide a statewide model of integrative public health programming across the life span. Major functions include: statewide development and implementation of program practices and policies; development of federal grant applications; development and enforcement of standards and guidelines related to chronic disease, family health including children with special needs, injury, nutrition and tobacco prevention and control; and evaluation of existing and proposed legislative proposals. For example, a major emphasis of programs within the Family Health Section involves prevention (including injury prevention), early screening and early intervention. The Wisconsin State Injury Prevention and Control Statute (255.20) directs the Department of Health Services to maintain an Injury Prevention Program. This includes data collection, surveillance, and education; provides local agencies technical assistance for effective program development and evaluation; and collaborates with other state agencies to reduce intentional and unintentional injuries. 18

19 CDC funding is distributed to the states for these and other program areas. This funding can be used by local communities for prevention of other diseases and injuries. The Division of Public Health distributes the funds to local health departments through the Grants and Contracts (GAC) negotiations process. The information from community health assessments is used to identify priorities, and then plan and implement programs and services to improve the health of the community. Remember the generalized public health nursing program from Module 1? For more information on the role of the public health nurse in community health assessments, refer back to Module 1 and HFS 140. Refer to Grants and Contracts (GAC) to learn about the negotiations process and how to combine funding for objectives your department assesses are needed in your community. The Centers for Disease Control and Prevention has resources as shown here and in the following slides, for health departments to utilize in developing or to assist in implementing local public health interventions at community and system levels of practice. This website is an excellent for information on best and evidence-based practices. Public health nurses can search here for credible resources including data, PowerPoint presentations, and other materials for community and professional education available free-ofcharge to local health departments. 19

20 Here are some specific examples of resources that apply to Prevention of Chronic Diseases and Injuries that can be found at CDC. - Injury center - Designing & building health places 20

21 This section covers application examples. Practical applications You might already know, there are different levels of prevention. We have utilized this model for more than half a century. A classic reference describing this concept is attributed to the work of Leavell & Clark (1953). They described the levels of prevention in this chart. This model is commonly applied in nursing and medical practice. The greatest contribution of the public health system is primary prevention. Primary prevention focuses on the population and the environment. (SHP2010) In the upcoming slides, we will consider examples in which public health nurses might apply interventions to prevent disease and injury. 21

22 Tobacco prevention - A public health nurse partners with the local tobacco prevention coordinator to present the health effects of tobacco at the local chamber of commerce meeting. Following the presentation, member agencies have requested assistance to develop smoke-free work policies and implement tobacco cessation benefits for the employees. Which level of prevention does this address? Secondary prevention detects and treats problems in the early stages. It prevents problems from causing serious or long-term effects or from affecting others. It identifies risks or hazards and modifies, removes, or treats the problem before it becomes more serious. Secondary prevention detects and treats problems early and targets populations that have common risk factors. Diabetes prevention - The Regional Public Health Nurse Consultant informs local health departments that new evidence based diabetes care guidelines have been released. A workshop has been scheduled for local health department nurses to assist in implementation of guidelines with community partners. A local PHN sees the opportunity for partnership with other care providers in promoting optimum diabetes treatment to prevent or delay complications. This would be considered Tertiary prevention. This level of prevention keeps existing problems from getting worse and is implemented after a disease or injury has occurred. The focus is on populations who have experienced disease or injury. An example would be assuring 22

23 that diabetes treatment standards are implemented by health providers to prevent further complications such as blindness, renal disease, or amputation. How would a PHN be able to implement these guidelines at a community level to improve care for the population with diabetes? Educate the community leaders involved in clinics, worksites, health care organizations, other public health nurses, MDs, long term care by holding a community educational session. Partner with other providers to hold a community town hall meeting to discuss resources available in the community and discuss options to prevent the onset of diabetes and to promote good health practices for the population with diabetes. Write a special health column in the local media, present a health segment on a talk show, and/or TV talk show. Invite other well respected health providers to assist you in the campaign. Meet with community groups to promote good health and discuss ideas on how to implement personal skills. Meet with Diabetes Educators in the community based and private clinics to assist in implementing the care guidelines in their respective clinics and health care system. Primary prevention both promotes health and protects against threats to health. It targets a healthy population and implements actions and programs to reduce susceptibility and exposures to risk factors. This is one of the key elements that distinguishes public health nursing from other nursing specialties. (Public Health Nursing: Scope & Standards of Practice, 23

24 2007). Consider the following case study example of a community-systems level intervention that was implemented by a public health nurse. This will be presented in the CDC success story format, which used to market public health. This is the Assessment component of the nursing process implemented at the community-systems level. A public health nurse observed that serious traffic conditions in many neighborhoods kept residents from daily physical activity and contributed to a significant number of pedestrian and bicycle crashes. She convened a multidisciplinary team for community needs assessment to guide program planning. She contacted the Wisconsin Department of Transportation for data, and found that, of 4,232 pedestrians and bicyclists in the Community that had been involved in a motor vehicle crash in the previous 5 years, on average 93.8% were seriously injured and 1.5% resulted in death. In the most recent year, a critical increase in pedestrian injuries resulted in 17 deaths, double that of previous years. As she reflected on this data in relation to the health priorities in the State Health Plan, she was impressed that in the last three decades, we have gone from being a society that walks and bikes to places in our neighborhoods and watching out for each other to one where we drive alone in our cars or stay in our homes if public transportation is not available; traffic engineers and law enforcement prioritize the rights of cars, rather than pedestrians; costly health and injury problems reduce our quality and length of life. 24

25 Next in Nursing Process is the Intervention and plan. The public health nurse requested, in collaboration with WI Walks, that local law enforcement work with public health professionals, engineers, educators, and elected officials to promote a healthier and safer traffic environment. The collaboration convinced city elected officials to allocate more city funds for safer walking conditions. This citywide effort to re-establish activity in neighborhoods focused on six pilot schools and a major employer. Five additional business areas requested collaborative interventions to improve patrons safety in accessing their businesses. The best practice 4 E s (Education, Enforcement, Engineering, and Encouragement) were used to re-knit the fabric of the community. Pedestrian traffic law enforcement has higher priority with the Police Department. Ten walking workshops were held in neighborhoods around six public schools and four business districts, with three more scheduled near parochial schools. Safe Routes to School program educational materials were provided to the schools for teachers to incorporate physical activity into academic curriculum. 225 schools distributed information about children s developmental readiness to cross streets independently and encouraging families to walk to places in their neighborhood. 964 children practiced safe street crossing and cycling, and learned about the importance of physical activity in their daily lives. 12 walking school buses were organized - adults shared the responsibility of walking children to school. City workers in three departments were encouraged to increase personal physical activity and to pace driving behaviors. The StreetShare program, emphasizing pledges to drive the speed limit and stop for pedestrians, was implemented. Media coverage included press conferences covering the kickoff, the national site visit ( Tour de Schools ), and the step-out projects in business districts; and billboards. And finally, Evaluation! In just two years, Safe Routes partnership achieved the following short-term outcomes in the Community: The departments of police, health, and engineering, the public school system, the faith community, business leaders and citizens are working together for a healthier and safer city. Pedestrian traffic law enforcement has higher priority with the Police Department. Traffic calming methods are systematically applied throughout the Community, as funding permits. The Community approved and hired a Bicycle Pedestrian Coordinator. Social 25

26 connectedness in a diverse urban setting increased. The community is starting to move more together, to make streets safer for children and for everyone all the time, everywhere! More steps: A pledge drive encouraging residents to commit replacing one trip per week with active transportation. An issue paper informing an asthma coalition s stakeholders regarding the impact of alternative transportation on air quality and emergency department visits for asthma. A letter to a bicycle pedestrian advocacy organization linking the health priorities to the need for bike racks on buses (cited at a public hearing, resulting in a unanimous vote of approval!). There are so many things that public health nurses can do, to assure healthy communities! A simple description of a program s progress, achievements, or lessons learned is a success story. With varying levels of evidence, a success story shows movement in your program s progress over time, its value and impact. More importantly, a success story serves as a vehicle for engaging potential participants, partners, and funders. With attention to detail, a system of regular data collection and practice, this story can become a powerful instrument to spread the word about your program. 26

27 This program was developed through a partnership between the Wisconsin Department of Health Services and the University of Wisconsin-Madison School of Nursing through the Linking Education and Practice for Excellence in Public Health Nursing Project funded by HRSA. We would like to thank the many nurses in academic and practice across the State of Wisconsin who contributed to this program by providing expert consultation and content review. Expert Consultation for this module on prevention of chronic diseases and injuries was provided by the Wisconsin Division of Public Health including Linda Hale and Cindy Musial, and Ann Stueck in the Bureau of Community Health Promotion. References: American Nurses Association. (2007). Public Health Nursing: Scope and Standards of Practice. Silver Spring, MD: American Nurses Association. Ervin, N. E. (2002). Advanced Community Health Nursing Practice/Population-Focused Care. New Jersey: Prentice Hall. LARRY ADELMAN Series Executive Producer & Co-Director of California Newsreel, Unnatural Causes, 2008 Leavell and Clark, 1953 Turnock,