Documenting Health Promotion Services in Community-based Nursing Centers

FEATURES Documenting Health Promotion Services in Community-based Nursing Centers M. Elaine Tagliareni, EdD, RN Eunice S. King, PhD, RN A data-collection tool developed to document health promotion services and describe program participants was used by 7 community-based nursing centers for 12 months. Data analysis results found that a wide range of services were offered to target populations across the life span, with adults aged 60 and older being the largest group of program users. KEY WORDS: community-based health promotion, community-based nursing centers, nurse-managed health centers, primary care centers, wellness nursing centers Holist Nurs Pract 2006;20(1):20 26 Nurses have historically played a critical role in the delivery of community-based health promotion programs and services essential to achieving the Healthy People Objectives for the Nation. Many of these programs are conducted by faculty and students in schools of nursing, and others are conducted through nurse-managed health centers. 1,2 The National Nursing Centers Consortium (NNCC), located in Philadelphia, Pa, the first organization of its kind to support the growing movement of nurse-managed health centers, has a membership of more than 200 centers designated as either primary care centers or wellness nursing centers. Although the exclusive focus of services in the wellness centers is on health promotion activities, almost all of the primary care centers offer community-based health promotion services and programs, as well, designed to promote health and optimal functioning among target populations and communities. 3 5 In each setting, professional nurses provide patients across the life span with direct access to a wide range From the Independence Foundation (Dr King) and Department of Nursing, Community College of Philadelphia (Dr Tagliareni), Philadelphia, Pa. Funding for this project was provided by major grants from the Independence Foundation. Appreciation is extended to Karen Karner and Carol Heinrich, East Stroudsburg University; Lydia Greiner, Fairfield University; Kay Huber, Messiah College; Wanda Dooley, Northern Virginia Community College; Carol Smith and Karen Grant, Pennsylvania State University; Nancy Rothman and Rita Lourie, Temple University; and Ivory Coleman, Jean Byrd, and Laureen Tavolaro-Ryley, Community College of Philadelphia. Special thanks are extended to the staff of Institutional Research and Information Technology, Community College of Philadelphia. Corresponding author: M. Elaine Tagliareni, EdD, RN, Department of Nursing, Community College of Philadelphia, 1700 Spring Garden St, Philadelphia, PA 19130 (e-mail: etagliareni@ccp.edu). of health promotion and disease-prevention services provided individually or in group settings and determined by the target populations served. In partnership with local healthcare providers, both public and private, nurses at wellness nursing centers augment existing primary care services. Historically, data collection in these centers has varied, and recording structures to collect and analyze health promotion and disease-prevention data for aggregate target populations have been limited and disparate. In spite of the importance of these programs in promoting the health of the communities and constituencies served, funding to support them has been problematic and has come largely from private foundations and highly competitive governmental grants. As part of its mission to strengthen the capacity and growth and development of nurse-managed health centers to provide quality healthcare services to vulnerable populations and to eliminate health disparities in underserved communities, the NNCC has secured federal funding, which has enabled several of its centers to implement programs such as Lead-Safe Babies and Asthma Safe Kids. 6 As funding for such programs has become increasingly more competitive, the collection of aggregate data documenting the scope of services provided and the constituencies served has become imperative. In addition to supporting funding applications, aggregate data that describe constituencies served and types and patterns of services provided in nurse-managed wellness centers provide a basis for identification of best-practice guidelines. This article describes a data-collection tool developed and tested by 7 nursing centers to document the scope of their health promotion programs and 20

Documenting Health Promotion Services in Community-based Nursing Centers 21 TABLE 1. Characteristics of participating nurse-managed centers Nursing center Location Target population(s) Community College of Philadelphia East Stroudsburg University, Wellness Center Fairfield University, Health Promotion Center Messiah College, The Wellness Center Northern Virginia Community College, Nurse-Managed Health Care Network Pennsylvania State University, Rural Nursing Center Temple University, Temple Health Connection Lower north Philadelphia; urban environment Monroe County, Pennsylvania; rural setting Bridgeport, Conn; urban environment Dauphin County, Pennsylvania; rural setting Northern Virginia; suburban community Rural Central Pennsylvania Upper North Philadelphia; urban environment Residents of lower North Philadelphia from across the life span Older adult participants in Area Agency on Aging Prime Time Health Program Residents participating in citywide initiatives representing all ages; residents in 2 independent living, high-rise housing for senior citizens Residents in 2 public housing facilities located in a small central Pennsylvania town Residents served by county social services network, with a focus on immigrant populations Older adults and residents with limited access to primary care and supportive services Residents of the surrounding community, the majority of whom resided in public housing facilities activities and to describe the clients served. It then presents the data collected by these centers from August 2003 through July 2004 and discusses how the data have been used in generating research questions and in supporting funding applications. DATA COLLECTION Collection of data describing participants in health promotion programs has been a challenge for many reasons. Many attendees of group programs dislike completing forms, even brief surveys that collect basic demographic data; some are unable to complete the forms without assistance, which might not be available; and, in some situations, dread of surveys can be a deterrent to program attendance. Furthermore, in some facilities where health promotion programs are conducted, such as schools and congregate living facilities, strict policies regarding the request for students or residents personal information preclude collecting specific individual data. To circumvent such problems, this instrument was designed to collect data that could not be associated with any individual participant. In addition, it was designed to be completed by one of the professional or nursing student program providers in a minimal amount of time, so as not to detract from service delivery, yet still allow for the capture of important data about the scope of services provided and characteristics of the clients served. The health promotion data-collection tool was developed over the course of 4 years, 2001 through 2004. Faculty from the Community College of Philadelphia s Department of Nursing designed the first iteration for use by students working within its 19130 Zipcode Project, a wellness center without walls, and led the subsequent revisions and testing. Since it was important to validate tool utility and fit for centers providing disparate ranges of services and targeting a wide range of clients, the tool was tested in 7 NNCC-affiliated nursing centers. As Table 1 shows, the 7 NNCC-affiliated nursing centers comprising the pilot sample served divergent populations in rural, urban, and suburban settings. Each of these centers offered a wide range of health promotion services and programs on the basis of (1) a needs assessment of the local community, in collaboration with strategic key informants, and (2) guidelines specified in the Healthy People 2010 Goals for the Nation 7 for the specific target populations served. For example, in some centers, the needs assessment dictated programming toward specific target groups (eg, teaching about immunizations to parents of toddlers and preschoolers participating in Head Start Programs; conducting medication brown bag events in senior high-rise apartment complexes) and toward meeting outcomes established through local funding initiatives (eg, development of a lead screening and awareness program in response to increased lead levels in an urban environment; establishment of a cardiovascular health promotion

22 HOLISTIC NURSING PRACTICE JANUARY/FEBRUARY 2006 TABLE 2. Stages in development of health promotion data-collection tool Tool development stage Major activity Tool revisions Stage 1 Stage 2 Stage 3 Stage 4 Paper & pencil form developed to list HP activities and record the number of participants Test new tool in CCP site. Data entered in Microsoft Access program Data-collection tool converted to Web-based tool use and testing expanded to 5 sites; group training conducted for all sites. Tool use and testing expanded to 7 sites; group training conducted for all sites The 4 Omaha categories of nursing interventions were used as categories for HP activities. Comprehensive lists of activities for each category and a data dictionary were developed Distinction made between HP activities conducted in group setting vs individual setting. Surveillance category added to group tool; individual tool redesigned to track referrals Addition of nursing center as type of usual provider ; delineation of wellness education into primary prevention and secondary/tertiary; addition of baseline as category for screening results; clarification of definition of screening for depression and functional assessment Deleted activities <5% of the total; added Health and Life Management as an element of the Health Teaching, Guidance, & Counseling category; completed other revisions to improve ease of use and comprehensiveness program for high-risk adults in a rural community where access to primary care providers was limited). Healthy People 2010 objectives, specifically those related to educational and community-based programs, provided benchmarks for targeting specific programming to improve access to information about prevention of suicide and depression, tobacco use, human immunodeficiency virus/acquired immunodeficiency syndrome, sexually transmitted disease infection, unhealthy dietary patterns, cardiovascular health, and cancer awareness. All other initiatives were directed toward achieving the Healthy People 2010 goals of increasing the proportion of residents from high-risk populations (eg, preschool children and parents, middle, junior, and senior high school students, adults older than 65) who receive consistent and supportive healthcare information. DESCRIPTION OF THE DATA-COLLECTION TOOL The tool underwent a series of stages in its development, as outlined in Table 2, characterized by testing (ie, using the instrument to collect data), assessing the instrument s ability to adequately capture important data, and then revising it to improve its accuracy and ease of use. There are 2 slightly different versions of the data-collection tool: one for health promotion activities conducted in groups and the other for those conducted in individual settings. Data collected during group-directed activities are referred to as group data, and each program attendee is considered an encounter. Because many individuals attend more than 1 program, the total number of encounters is a duplicated count, reflecting total attendance at all programs, not the total of individual participants. Individual data are collected during one-to-one sessions (encounters) between the nurse and the client occurring in a nursing center, community agency, or the client s home. As with the group data, the aggregate number of individual encounters could include multiple sessions with the same client and thus do not reflect the number of actual individual clients served. All referrals made following or during group encounters are recorded as individual data. The instrument organizes the health promotion activities into 1 of 4 categories, which are based on the nursing intervention categories specified by the Omaha System 8 : (1) Health teaching, guidance, and counseling, for example, dental care education, safety education, cardiovascular health, and health and life management; (2) Surveillance, for example, height and weight measurement, vision and hearing screening, glucose monitoring, blood pressure evaluation; (3) Case management, for example, referral for follow-up services, medication management; and (4) Administration of treatments and procedures, for example, wound care, first aid. For each category, a list of activities, specific enough to be informative, yet generic enough to capture all centers

Documenting Health Promotion Services in Community-based Nursing Centers 23 activities, has been developed and modified multiple times over the course of the tool development. A data dictionary giving explicit directions and examples of how activities should be coded was developed and underwent extensive testing and revision. As noted in Table 2, in Stage 4, an additional element, Health and Life Management, was added within the health teaching, guidance, and counseling category to fully capture the scope of services most often provided to clients aged 60 and older, for example, helping the client arrange transportation, calling pharmacies on behalf of patients, and negotiating reimbursement with insurance carriers. For those centers that targeted wellness services directly to older adults, finding a waytocapture the advocacy role was of paramount concern. Procedures During each group session, a designated recorder counted the number of participants and categorized them according to racial background and broad age groups, for example, 20 attendees, all aged 60 or older, 10 African Americans, 5 whites, and 5 Asians. Then the nurse checked all activities offered during the course of the group session, for example, health teaching about signs and symptoms of cardiovascular disease, medication management, and nutrition counseling. Demographic and healthcare utilization data collected for individual encounters were self-reported through interviews with clients. For children seen in head start programs or in elementary schools, agency records were utilized; if data were not available, they were recorded as unknown. RESULTS Service locations Although the location for the health promotion and disease-prevention activities varied, 21% of group activities occurred in schools, ranging from preschools and head start programs (9%) to elementary (6%), middle (4%), and high school (2%), and 26% were conducted in a nursing center or senior citizens facility, with the remaining 50% conducted in various community locations, including public housing facilities. In contrast, only 5% of individual encounters occurred in school settings, with the majority conducted in the nursing wellness centers or in senior citizens housing facilities. Client characteristics During the reporting period, more than 1100 groups were conducted, with a total attendance of 22,507 and an average of 19 encounters per group. The number of one-to-one individual encounters totaled 4317. More than half of these were for surveillance (53%), 25% were for health teaching, guidance, or counseling, 7% for immunizations, and 15% for treatments. Of the 4317 individual encounters, 1315 occurred subsequent to group programs or activities and usually were for the purpose of discussing a referral for follow-up of abnormal screening results. Considerable variation was found between the racial backgrounds of participants in the group-directed programs versus the individual-directed programs. Since staff estimates the race for group participants, rather than query them individually, the data provide an approximation of the racial background of participants. Slightly more than half of the participants in the group programs were African American (54%), followed by white (24%), Asian (3%), and other (19%). Among the individual encounters, almost half (49%) were with white clients, followed by African American (26%), Asian (5%), and other races or combinations (20%). Differences between the predominant racial backgrounds of group versus individual encounter participation reflected demographic differences in the populations served by centers that offered primarily individual-directed activities versus group-directed activities. For example, Temple and Community College of Philadelphia located in Philadelphia with a majority African American population conducted primarily group-directed programs, whereas Pennsylvania State University and Messiah College, located in predominately rural, white communities, conducted primarily individual-directed programs. Of the individual encounters, most occurred with adults aged 60 and older (40%) or with children in middle school and high school (15%), largely as a result of referrals made following group teaching and surveillance activities. Note that several of the participating centers targeted senior citizens specifically. Among the participants in group activities and programs, senior citizens again accounted for one of the largest groups attending group activities (23%), followed by elementary school children (16%),

24 HOLISTIC NURSING PRACTICE JANUARY/FEBRUARY 2006 TABLE 3. Group and individual data: Health teaching, guidance, and counseling Educational topic %Group programs % Individual encounters (n = 1167) (n = 4317) Dental care 3 28 Environmental, eg, lead prevention 34 15 Exercise 10 20 Family planning 22 3 Growth and development 3 7 Health and life management advocacy 7 11 Medication action/side effects 7 14 Mental/emotional issues 5 5 Nutrition (including breast-feeding) 19 20 Personal care 6 14 Safety (child safety, first aid, fall risk reduction, sun protection) 5 9 Secondary/tertiary prevention/signs and symptoms, including 24 25 management of chronic illnesses, eg, diabetes, asthma, cardiovascular illnesses, and mental health Stimulation/nurturance 11 3 Stress management 4 4 Substance use and abuse 12 6 Wellness primary prevention, eg, immunizations, prenatal education, human immunodeficiency virus/sexually transmitted disease prevention, cancer screening 25 40 Percentages reported represent percentage of the total number of programs. Since multiple topics may be covered during each encounter or program, the percentages total more than 100. Data were collected only during February to July 2004. middle/high school age (14%), preschoolers (13%), and young to middle-age adult clients (13%). In some groups, participants ages spanned a wide age range, which could not be readily categorized. As with the racial background data, the age data differed across sites and reflected the age of the centers target populations. Although the majority of individual encounters were with clients reporting some type of health coverage, for example, 25% reporting Medicare coverage, 18% Medicaid or a state-subsidized insurance program, 10% commercial insurance, and 12% some unspecified coverage, another 35% were with clients who did not have any insurance coverage. Most of the uninsured encounters were with members of immigrant populations, primarily at one center located at a large metropolitan locale. Although the majority of individual encounters were with clients who reported having a usual healthcare provider, that is, a physician (40%), a health clinic (28%), or a nurse practitioner (7%), 28% were with clients who did not have a regular provider. Another 10% were with clients who reported not knowing whether or not they had a usual source of healthcare and 2% with clients who reported using an emergency department as their usual source of healthcare. Usual source of healthcare data were not collected from participants in group programs because of the desire to minimize distraction from the program. Services provided Health teaching, guidance, and counseling These services were provided in both group and individual sessions. Included within this category were giving information, anticipating client problems, encouraging client action and responsibility for self-care and coping, and assisting with decision making and problem solving. As Table 3 shows, individual encounters focused primarily on wellness education (50%), dental education (28%), and nutrition education (16%). Teaching in these areas was often combined with education directed toward disease management, for example, signs and symptoms management education (25%) and management of medication and/or its side effects (14%). These 2 categories combined to account for more than 39% of the encounters between nurses and individual clients. This is important because education related to chronic disease management assists clients

Documenting Health Promotion Services in Community-based Nursing Centers 25 TABLE 4. Group and individual data: Health surveillance Group programs % participation Individual encounters % participation Activity (n = 1167) (n = 4317) Back screening, scoliosis 0.2 12 Bone density 22 0.5 Blood pressure 20 70 Cholesterol 4 10 Developmental screening 1 5 Depression scale (Prime MD) 0.3 2 Electrocardiogram <1 <1 Functional assessment <1 3 Glucose monitoring 5 13 Head lice screening 0 3 Hearing screening 9 5 Height/weight measurement 24 50 HGB/HCT screening <1 13 Lead screening 2 13 Pulse screening 3 19 Urine screening 2 14 Vision screening 11 20 Tuberculosis testing 1 2 Multiple services were provided during each encounter, making the percentage total more than 100. in maintaining self-care and sustaining independent living status, a major goal in the NNCC wellness nursing centers. Group encounters focused primarily on wellness education (25%), signs and symptoms education (23%), and nutrition education (19%). Surveillance Table 4 shows the specific services that were included in this category, all of which were aimed at detection, measurement, critical analysis, and/or monitoring clients status in relation to a given condition or phenomenon. All participants with abnormal findings were referred for case management, and the individual encounter tool was completed to record the type of referral indicated and where the referral was made. For example, for blood pressure screenings on the individual tool, 49% of referrals were made to the nurse at the wellness center and 39% to the client s physician. Among the referrals, 1319 came from group surveillance activities and 1935 from individual encounters. Blood pressure screening, together with height and weight measurement, accounted for the largest number of both group and individual encounters. Hypertension screening is a major initiative of all nursing centers because of the large number of older adults served by the centers. Similarly, since weight is used as an indicator of hypertension and cardiovascular risk and as an outcome to be evaluated, weight measurement accounted for more than 50% of individual encounters for surveillance. However, screening must be, and in fact was, accompanied by activities designed to promote clients ability to manage their hypertension, such as medication teaching and signs and symptoms education. (Although weight measurement was also conducted in school settings, its purpose there was to assess developmental status and obesity risk.) DISCUSSION The data collected by the 7 participating centers over a 12-month reporting period indicate that (1) a major group of consumers of health promotion activities, both individual and group directed, were adults aged 60 and older and (2) the services provided in fact were those that augmented those of primary care providers and may have contributed to senior s ability to maintain independent living. For example, during the February through July 2004 reporting period, the health and life management category, which included helping clients arrange transportation, calling pharmacies on behalf of patients, assisting with contacting insurance carriers, and conducting group programs on topics such as How to Use Your Medicare Prescription Benefit, represented more than

26 HOLISTIC NURSING PRACTICE JANUARY/FEBRUARY 2006 10% of the total group encounters and more than 21% of individual encounters with clients aged 60 and older. In addition, these data showed that cardiovascular education for individuals with existing cardiac problems, exercise classes, and hypertension management education constituted the largest number of health teaching services provided to the older adult population. These services, as well as many others, offered to clients in senior citizens housing communities were potentially facilitating independent living and clients management of complex chronic health problems. The rank ordering of health teaching topics offered to older adults during February to July 2004 was as follows: (1) Medication Action/Side Effects; (2) Health Life Management Advocacy; (3) Cardiovascular Education (Secondary and Tertiary Prevention); (4) Exercises; (5) Cardiovascular Education (Primary Prevention); (6) Hypertension Management Education (Secondary and Tertiary Prevention); (7) Diabetic Care Education (Secondary and Tertiary Prevention); (8) Mental/Emotional Education; and (9) Stress Management. This again led to additional questions about the importance of the nursing centers role in enabling older adults to manage their health issues and to sustain functional independence. These questions have spawned an in-depth pilot, qualitative study to explore how nurse-managed wellness centers assist senior adults in maintaining independent living. The data collected over the 4-year period of the health promotion data-collection tool development have guided numerous revisions to the instrument, which has now been effectively tested in 7 nursing centers. The tool has been found to adequately capture the scope of activities and services provided and to accurately characterize the clients served. When the data have been examined by individual centers, we noted considerable variation that reflected the demographic characteristics of the communities served and ultimately what emerged was an understanding that NNCC wellness centers are not homogeneous; services provided are dictated by the needs and characteristics of the community and populations served. Project staff worked cohesively and collaboratively to refine the health promotion data-collection tool so that it could be used by any NNCC wellness nursing center to capture the range of services provided and characteristics of clients served. Project staff, who originally sought to develop a tool that addressed the unique characteristics of their center and region, were able to develop a generic tool that has yielded data reflective of the comprehensive nature of the services provided and the clients served without becoming so specific that it is difficult to use. Hence, it has been well-accepted and used by staff in the participating centers to document their work. The data collected have been used to generate additional questions to be addressed and will also be used to identify and facilitate implementation of best practices for health promotion/disease-prevention programs. REFERENCES 1. Anderko L, Kinion E. Speaking with a unified voice: recommendations for the collection of aggregated outcome data in nursing centers. Policy Polit Nurs Pract. 2001;2:295 303. 2. Lundeen S. An alternative paradigm for promoting health in communities: the Lundeen Community Nursing Center Model. Fam Community Health. 1999;21(4):15 28. 3. Hansen-Turton T, Kinsey K. The quest for self-sustainability: nurse managed health centers meeting the policy challenge. Policy Polit Nurs Pract. 2001;2:304 309. 4. Torrisi D, Hansen-Turton T. Community and Nurse-managed Health Centers: Getting Them Started and Keeping Them Going. New York, NY: Springer Publishing Company; 2004:2 3. 5. Barkauskas V, Pohl J, Benkert R, Wells M. Measuring quality in nursemanaged centers using HEDIS measures. J Healthc Qual. 2005;27:4 14. 6. National Nursing Center Consortium Programs. Available at: www.nncc.us/programs. Accessed August 1, 2005. 7. US Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: US Government Printing Office; 2000. 8. Martin K, Leak G, Aden C. The Omaha system: a research-based model for decision-making. In: Spradley BW, Allender JA, eds., Teachings in Community Health Nursing. 5th ed. Philadelphia: Lippincott-Raven; 1997:316 324.