A Summary of the December 2009 Forum on the Future of Nursing Care in the Community (2010) / Chapter Skim
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3 Community and Public Health
3 Community and Public Health
Pages 15-24
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From page 15... ...
The most common diagnoses among VNSNY's patients are chronic conditions, including diabetes, hypertension, and congestive heart failure 1 Congregate care facilities are residential settings that typically provide social activities, security, and assistance with instrumental activities of daily living (e.g., meal preparation, housekeeping, transportation)
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For home care patients, the coordination of interdisciplinary care is a critical function of visiting nurses. They help patients recover and regain functioning, learn to manage their own conditions, avoid exacerbations in chronic conditions, and build up strength and endurance.
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In the 2 years since VNSNY started implementing transitional care, the rehospitalization rate of home care patients dropped from 27 percent to 23.5 percent, said Raphael. VNSNY also operates a Nurse-Family Partnership program, such as the one described by Mary Selecky in Chapter 2, that ensures prenatal care; educates prospective parents about newborn care; fosters the physical, emotional, and cognitive development of children; and links families to other community supports and programs.
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Information in the mobile system is evidence-based, which forces providers to think about how their actions apply to different chronic conditions. The system also generates quality measures based on outcomes, processes, satisfaction, and utilization, with each care team receiving its quality results.
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A nurse internship program offers new bachelor's degree nursing graduates hands-on experience and mentoring by seasoned staff to prepare them for home-based nursing. Thirty members of the nursing staff are adjunct faculty at nursing schools.
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This table demonstrates projected demand at the national level using baseline assumptions defined for HRSA's Nursing Demand Model. However, demand at the state level varies significantly.
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This table demonstrates projected demand at the national level using baseline assumptions defined for HRSA's Nursing Demand Model. However, demand at the state level varies significantly.
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5. Establish quality in community care as a core competency for all nurses.
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Raphael said that her organization has attracted people from other fields, such as financial services or the media, who are interested in becoming nurses, but "it is not easy to make that leap." The largest source of nurses for VNSNY is the acute care setting. The organization has a 3-week orientation program for nurses from acute care or nursing homes to introduce them to community care, followed by continuing education.
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"Some of the nurses are welcoming that role, and this is a technology we are looking at seriously." She also said that VNSNY nurses often take photographs of wounds and show the photographs to wound care specialists and physicians to determine if a therapy needs to be changed. "One of the most important things we can do is link with the primary care physician and be able to exchange clinical information on a continuous basis," she noted.
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