Nurses as Change Agents in the CommunityAs in all assignments, cite your sources in your work and provide references for the citations in APA format..In the chapter, “How Community-Based Organizatio

CHAPTER 84

How Community-Based Organizations Are Addressing Nursing's Role in Transforming Health Care

Mary Ann Christopher, Ann Campbell

“The day may soon dawn when we Americans can enjoy a measure of life and health that is consistent with our extraordinary resources and the intelligence of our people. The pioneers have begun their work; it is far from finished. New fields, new enterprises, are visible. The times call for the high spirit of the courageous pioneers among physicians, scientists, and nurses.”

Lillian Wald

This is a time of rapid transformation in health care, one in which community health nursing has a critical role in advancing individual and public health. As the United States integrates the mandates of the Affordable Care Act (ACA), community health organizations have a pivotal role in affecting the health status of the nation, particularly for vulnerable populations. The Institute for Healthcare Improvement, through the construct of the Triple Aim, calls on all members of the health care team to improve the health of the population, improve the consumer experience and reduce the cost of care. The Institute of Medicine's (IOM) report on The Future of Nursing has charged nurses to become equal partners in the development of health policy and practice (IOM, 2011). The IOM report Public Health and Primary Care has challenged practitioners to coordinate efforts for the betterment of patients (IOM, 2012a).

Community-based organizations are strategically positioned to provide the leadership as well as the integration and coordination of services necessary to carry out these aims. Further, the community-based sector of the nursing profession is poised to influence the transformation of health care delivery by drawing on principles that are core to the discipline. By partnering with communities, creating innovative approaches to care as the system evolves, and engaging the communities they serve, community health nurses can deliver on the promise of quality health care for all. This chapter discusses the approaches of the Visiting Nurse Service of New York (VNSNY) to mobilize the strengths of the community to improve public health, establish cross-continuum interprofessional teams to affect the continuum of the patient care journey, and promote public policy to advance funding methodologies that more adequately consider risk factors of vulnerable populations.

Community as Partner and the Community Anchor

Community Anchor is a concept that is being developed by the VNSNY as a way to build healthier communities. The Community Anchor is a term that suggests if nursing is going to exercise its responsibility for the individual as well as public health, the profession must recommit to its traditional focus on grassroots needs assessment and service provision, so brilliantly illustrated by the work of Lillian Wald, founder of the Henry Street Settlement House, the VNSNY, public health nursing, 665occupational health nursing, the first playground in New York City, and more. To best meet the health needs of individuals, nursing must work in partnership with the community. These part­nerships act as bridges, connecting public health nursing both to individuals and to the wider community.

The Community Anchor works locally to build or support programs that address social determinants of health, offering reinforcement to communities as they work on revitalization efforts. The Community Anchor uses the community needs assessment to inform program development and create a foothold in the community's areas of vulnerability and strengths, and weaves solutions in tandem with the community. The Community Anchor teams comprise interprofessional members, who in most cases are members of the communities they serve. The following questions help the team to develop key organizing constructs that guide their interventions:

• What are the strengths and assets of the community?

• What are the needs and goals that the community identifies for itself?

• Who are the key stakeholders?

• What are the goals in care?

• What community initiatives are already underway upon which we can build?

Once these questions are answered, tools for the development of Community Anchor initiatives include:

• Mobilizing front-line public health visiting nurses to identify unmet needs and strategic directions of the community

• Mapping assets, or inventorying the assets and gaps in community resources and potential, across a broad spectrum of health, mental health, social service and housing providers, and faith-based coalitions

• Identifying existing community action groups and fostering collaboration

• Partnering with hospitals, ambulatory care networks, and other players to better address the health needs of the community

The Community Anchor strategy, by design, takes different forms based on unique characteristics of each community. In Washington Heights, a diverse, at-risk community in upper Manhattan, the anchor initiative has taken the form of a Health Village, aimed at impacting the self-care management of community residents 60 years of age and older diagnosed with diabetes mellitus. The VNSNY has partnered with supermarkets, housing pro­viders, primary care providers, and an academic medical center to create a safety net of support around a low-income population struggling to follow through with treatment regimens. This patient-centered community network provides the access points for the residents to receive care and coaching in support of their self-management. In fact, residents can access any of the health or social services providers through this community network. It becomes the vehicle for their connection to a comprehensive system of health and social service providers.

In an area of the Rockaways on Long Island that was hit hard by Superstorm Sandy, the anchor initiative focuses on developing specialized registered nurses and licensed clinical social workers, called community wellness coaches (CWCs), with the goal of integrating medical and social services to achieve health promotion and disease prevention and to avert unnecessary emergency department visits. Funded by a New York State Social Services Block Grant, the CWCs direct teams of wellness navigators (WNs), who live in the neighborhoods they serve, centered around hot spots such as senior housing sites, pharmacies, churches, and community centers where health disparities are high and access to services is low. The VNSNY blends lessons learned from its experience in post-Superstorm Sandy recovery efforts with evidence-based elements from a number of coaching models that target at-risk populations, including the Geisinger ProvenHealth Navigator Model (Hospitals in Pursuit of Excellence, n.d.), the Kaiser Grace Model (Bielaszka-DuVernay, 2011), the Care Transitions Intervention (Coleman et al., 2006), and the Transitional Care Model (Naylor et al., 2011).

The objective of this Community Anchor initiative is to conduct outreach to 5000 community residents over a 24-month period through two programs: 1000 residents will be reached through a one-on-one intervention model, and 4000 will be 666impacted through a group-focused public health model. For the 1000 members in the CWC program who receive one-on-one coaching, community members are paired with the professional coaches for no less than 3 monthly visits. The community health nurses and social workers structure their interventions within the health coaching framework: self-management support, serving as a bridge between clinician and patients, navigation of the health care system, emotional support, and continuity (Bennett et al., 2010). To ensure that the intervention is culturally competent and relevant, WNs are recruited from the neighborhoods they serve to extend the intervention of the professional coaches. The role of the WNs involves fostering patient engagement, facilitating adherence to the plan of care, reinforcing health teaching, and assisting with negotiation of the health care system. The employment of local people likewise facilitates the economic development of the neighborhoods. Among those who serve as WNs are VNSNY home health aides who were promoted to this role and then immersed in a structured course of health navigation and coaching. With this enhanced competency, they now have advanced on the career ladder as well, fulfilling the charge of the IOM Future of Nursing report that each member of the interprofessional team function at their highest level of education and training (IOM, 2011). This commitment to the direct care workforce further supports the needs of economically disadvantaged communities.

Building on the assets of the community, the interprofessional teams promote public health by employing an aggregate approach to health intervention. Partnering with key community stakeholders, they design and implement Community Wellness Campaigns aimed at increasing awareness and linking community members to resources on weight management, age appropriate immunizations, health screenings, cardiovascular health, nutrition, and mental health.

Accountable Care Community

A longer-term initiative that will leverage these partnership approaches is the accountable care community (ACC). A concept developed in Akron, Ohio, the ACC focuses on integration within a specific geographic area to bring about improved health outcomes. The ACC encompasses the medical and public health systems, community stakeholders at the grassroots level, and community organizations whose work often encompasses the entire spectrum of the determinants of health (Janosky et al., 2013). Our goal is to obtain federal demonstration funding to test the model of care in collaboration with partners in Nassau County. Through this project, the VNSNY would extend its efforts through geographic morbidity and mortality mapping to at-risk neighborhoods. In a partnership with the community, a public hospital, local housing providers, and social services organizations, visiting nurses would function as population care coordinators to develop a population-based intervention model through which all partners, including community residents, have the opportunity to share in financial rewards that will result once improved health outcomes are achieved.

Superstorm Sandy

This work expands on an approach that the VNSNY has been implementing in a community significantly devastated by Superstorm Sandy. Project Hope is a strengths-based model in which the VNSNY recruited members of the community who had effectively overcome the impact of the disaster to work as crisis counselors, fostering resiliency among survivors within the community. A survivor is defined as someone who is experiencing a “normal reaction to an abnormal situation,” and the goal is to empower the survivor to draw upon his or her preexisting coping skills. The crisis counselors work with the survivor to problem solve, provide resources, and support the survivor in taking actions to recover, encompassing a range of behaviors, such as scheduling medical appointments, securing Federal Emergency Management Agency (FEMA) funding, negotiating home insurance coverage, and promoting optimal functioning within the family unit. The survivors regain a sense of control and accomplishment. Pro­ject Hope, funded through a public/private partnership, has 667resulted in the provision of over 20,000 community-based visits to those suffering posttraumatic stress from the impact of the storm. This strengths-based intervention model addresses the mental health impact of disaster and reaches out to those who have become isolated, toppling the disparities that arise when homes have been lost, communities leveled, and services destroyed.

This work has facilitated VNSNY's ability to highlight and institutionalize nursing's role in emergency and postemergency relief work. Through participation on city, state, and regional commissions, we have formalized the role of nursing in the standards for community response. Within the policy briefings that have been forthcoming from this event, community nursing stands embedded along with the environmental, health and human services, housing, communications, and transportation responses that impact societal resiliency.

Recognizing that the goals of the Triple Aim and the promise of the ACA depend on this commitment to community, the VNSNY made an intentional decision to transform the system of care in our market by enhancing the competency of our nurses to address both the individual and population health. Through a partnership with Duke University and New York University, the VNSNY has immersed cohorts of its nursing staff in a semester-long curriculum focused on population care coordination. Nurses gain enhanced exposure to the constructs of epidemiology, community assessment, predictive analytics, and social determinants of health. Armed with these competencies, nurses are assuming leadership roles in designing and implementing community anchor initiatives, accountable care organizations, and payer-based care coordination infrastructures. Nurses are demonstrating their roles as “…full partners, with physicians and other health care professionals, in redesigning health care ...” (IOM, 2010).

Nurses at the VNSNY are using these and other competencies to weave together a cross-continuum system of care that facilitates the safe and meaningful passage of patients. National statistics underscore the imperative for this cross-continuum coordination. In care for the chronically ill, studies have shown that only half of the recommended services are provided (IOM, 2010). If the quality of care were to improve in each state to match that in the highest performing states, an estimated 75,000 lives could be saved each year (IOM, 2012a, 2012b). Care quality, then, is critical to the path forward and partnerships are vital to this aim.

the Population Care Coordinator

Shifting from a fee-for-service reimbursement environment to one that is value-based requires a change in practice among front-line community health nurses with regard to financial, quality, and population management concerns. In the past, reimbursement was based on the number of pati­ents seen and the particular comorbidities of each patient. Under the value-based model, payment is based on a number of factors linked to care quality. Hospitals are penalized when their patients are readmitted within 30 days of being discharged, and patient satisfaction scores are measured and reported publicly, which influences consumer engagement and choice. Community health nurses must intentionally link discrete interventions to patient outcomes, most notably by preventing unnecessary rehospitalizations and by optimizing patient care experiences.

Hospital Partnerships and Transitional Care

The VNSNY has collaborated with health system partners to establish transitional care programs that facilitate shorter lengths of stay, mitigate the need for subacute placement, and significantly reduce first 30-day all-cause readmissions. The critical components of these programs include: cross-continuum clinical pathways, interprofessional participation and endorsement, warm handoffs at the bedside between acute care and home care nurses, risk adjustment methodologies, and the leadership of advanced practice nurses.

Nurses in community-based settings are participating in convening tables with health system partners to redesign the models of care that are patient-focused and community-centric. In one 668initiative, hospital length of stay for postoperative patients recovering from hip and knee replacements was reduced by 1 day through an interprofessional team effort that included bedside handoffs, the more effective management and anticipation of uncontrolled diabetes, the advancement of a rehab home health aide coach, and the implementation of an intensive rehab program, which eliminated the need for a subacute stay. The readmission rate for these patients was under 2%.

In another case of patient postcardiothoracic surgery, warm handoffs at the bedside between the acute care and the home care nurse, including focused patient and caregiver engagement, resulted in avoidance of subacute placement, a reduction in substernal wound infections, reduction in length of stay, rehospitalization rates below 10%, and higher patient satisfaction and caregiver engagement.

Another opportunity for community nursing to transform the delivery system is to affect the system of care that results in avoidable emergency department visits with resultant admissions. By adding a community health nurse to the emergency department team, the perspectives of the home and community as assets in the plan of care result in an assess-and-release approach that is more conducive to patient outcome. Among 622 patients assessed in the emergency department of one hospital by VNSNY nurses over a 6-month period, 59% went home directly rather than being admitted to the hospital. The community health nurse in the emergency department interfaces with the home visiting nurse and the community-based nurse practitioner who stabilize the plan of care and create the bridge to the primary care provider. This program has been so effective that new start-up insurance companies on the New York State Health Exchange are contracting with the VNSNY so that home care nurses in the emergency department will be alerted via text when a member of their health plan arrives in the emergency room.

If nurses are truly to affect the system of care, they must also impact health insurance companies. Nurses at the VNSNY did just that by engaging a health insurance company as a partner. Using a modification of the Naylor transitions of care approach, the VNSNY nurses and nurse practitioners partnered with a major insurer and a community hospital to address the incidence of unnecessary hospitalizations among health plan members. Members of the interprofessional team included hospital physicians, nurses, and social workers; VNSNY nurses and nurse practitioners; and nurse practitioners from the health plan. Weekly case conferences, including staff from the hospital, VNSNY staff, and nurse practitioners from the health plan, are conducted virtually for the establishment of the plan of care. Members who were hospitalized received a bedside assessment by a VNSNY nurse to determine their risk of readmission. Among the variables that drive risk acuity are: multimorbidity, polypharmacy, cognitive disability, mental illness, substance abuse, and previous hospitalization or home care admission within the previous 6 months. For those who exhibit the highest risk, a VNSNY nurse practitioner enrolls the patient in a 30-day transitional care program with focused care coordination by an interprofessional team. The 24-hour access to a nurse practitioner, which addresses issues such as medication adjustment, anxiety, and the management of symptoms, many of which occur disproportionately after hours, has been a gold standard for this program. This cross-continuum model, designed by nurses, has effected a 49% reduction in first 30-day all-cause readmissions.

Vulnerable Patient Study

Recognizing that the ultimate effectiveness of our work in impacting health care transformation rests on the degree to which it impacts reimbursement methodologies and policy considerations, the VNSNY has directed considerable effort to translating our knowledge of community-based health care to policy arenas. Through our care of vulnerable community-based populations, we have found that certain patient characteristics are predictive of the resource allocation that patients will ultimately require and that must influence reimbursement methodologies if these patients are to receive appropriate care. Through research conducted in partnership with the Visiting Nurse Associations of America, the VNSNY's Center for Home Care 669Policy and Research and 23 Visiting Nurse Associations across the country identified patient characteristics that are not adequately considered in the Medicare home health methodology. Those characteristics include: presence of a caregiver, socioeconomic status, con­tinence, clinical complexity, and uncontrolled chronic illness.

The results of this study have been shared with the Medicare Payment Advisory Commission, an independent organization established by the Balanced Budget Act of 1997, and the Centers for Medicare and Medicaid Services, which administers Medicare, Medicaid, and Children's Health Insurance Programs and coordinates with states to set up Health Insurance Marketplaces, expand Medicaid, and regulate private insurance (Centers for Medicare and Medicaid Services [CMS], 2013; Medicare Payment Advisory Commission [MedPAC], 2013). The goal of this advocacy has been to influence risk acuity of the Medicare system to more adequately address the needs of vulnerable populations. We are using similar predictive analytics and risk-adjusted methodologies to negotiate funding streams with private payers.

Conclusion

As the health care system continues to demand a commitment to the tenets of the Triple Aim, community health nurses have a central role to play in transforming the system of care. With a discipline anchored in an understanding of public health, with a practice that honors the assets of the community, and with a relationship-based competency that facilitates partnerships, community health nursing can and must execute on the IOM call for our profession to emerge as architects of a transformed health care system.

Discussion Questions

1. What are the ways in which a population health focus might be applied in the transforming health care delivery system?

2. What are some of the new constructs that nurses are integrating in promoting the health of communities?

3. What are the key foundational elements of a successful transitional care program?

References

Bennett H, Coleman E, Parry C, Bodenheimer T, Chen E. Health coaching for patients with chronic illness. Family Practice Management. 2010;17(5):24–29.

Bielaszka-DuVernay C. The “GRACE” model: In-home assessments lead to better care for dual eligibles. Health Affairs. 2011;30(3):431–434.

Centers for Medicare and Medicaid Services [CMS]. CMS strategy: The road forward 2013-2017. [Retrieved from]  www.cms.gov/About-CMS/Agency-Information/CMS-Strategy/Downloads/CMS-Strategy.pdf; 2013.

Coleman E, Parry C, Chalmers S, Min S. The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine. 2006;166(17):1822–1828.

Hospitals in Pursuit of Excellence. Case study: Proven Health Navigation at Geisinger Health System. [n.d. Retrieved from]  www.hpoe.org/resources/case-studies/1297.

Institute of Medicine [IOM]. The healthcare imperative: Lowering costs and improving outcomes. National Academies Press: Washington, DC; 2010.

Institute of Medicine [IOM]. The future of nursing: Leading change, advancing health. National Academies Press: Washington, DC; 2011.

Institute of Medicine [IOM]. Public health and primary care: Exploring integration to improve population health. National Academies Press: Washington, DC; 2012.

Institute of Medicine [IOM]. Best care at lower cost: The path to continuously learning health care in America. National Academies Press: Washington, DC; 2012.

Janosky J, Armoutliev E, Benipal A, Kingsbury D, Teller J, et al. Coalitions for impacting health of a community: The Summit County, Ohio, experience. Population Health Management. 2013;16(4):246–254.

Medicare Payment Advisory Commission [MedPAC]. About MedPAC. [Retrieved from]  www.medpac.gov/about.cfm; 2013.

Naylor M, Aiken L, Kurtzman E, Olds DM, Hirschman K. The importance of transitional care in achieving health reform. Health Affairs. 2011;30(4):746–754.

Online Resources

American Public Health Association.

 www.apha.org.

Care Transitions Program (Eric Coleman's Model).

 www.caretransitions.org.

Institute for Healthcare Improvement.

 www.ihi.org/Pages/default.aspx.

Transitional Care Model (Mary Naylor's Model).

 www.transitionalcare.info.

Visiting Nurse Associations of America.

 vnaa.org.

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