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| Current Bibliographies in Medicine | |
Current Bibliographies in Medicine 93-7
Community-Based Health Care Models
CBM 93-7 Community-Based Health Care Models January 1987 through August 1993 113 Citations Prepared by Catherine Roos Selden, M.L.S., National Library of Medicine Nancy Wiederhorn, D.N.Sc., R.N., National Institute for Nursing Research U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service National Institutes of Health National Library of Medicine Reference Section 8600 Rockville Pike Bethesda, Maryland 20894 1993 SERIES NOTE Current Bibliographies in Medicine (CBM) is a continuation in part of the National Library of Medicine's Literature Search Series, which ceased in 1987 with No. 87-15. In 1989 it also subsumed the Specialized Bibliography Series. Each bibliography in the new series covers a distinct subject area of biomedicine and is intended to fulfill a current awareness function. Citations are usually derived from searching a variety of online databases. NLM databases utilized include MEDLINE, AVLINE, BIOETHICSLINE, CANCERLIT, CATLINE, HEALTH, POPLINE and TOXLINE. The only criterion for the inclusion of a particular published work is its relevance to the topic being presented; the format, ownership, or location of the material is not considered. Comments and suggestions on this series may be addressed to: Karen Patrias, Editor Current Bibliographies in Medicine Reference Section National Library of Medicine Bethesda, MD 20894 Phone: 301-496-6097 Fax: 301-402-1384 Internet: patrias@nlm.nih.gov Ordering Information: Current Bibliographies in Medicine is sold by the Superintendent of Documents, U.S. Government Printing Office, P.O. 371954, Pittsburgh, PA 15250-7954. To order the entire CBM series for calendar year 1994 (approximately 10 bibliographies), contact the Superintendent of Documents citing GPO List ID: CBM94. For your convenience an order blank is given inside the back cover. Orders for individual bibliographies in the series should also be sent to the Superintendent of Documents citing the title, CBM number, and the GPO List ID. Internet Access: The Current Bibliographies in Medicine series is also available at no cost to anyone with Internet access through FTP (File Transfer Protocol). FTP to nlmpubs.nlm.nih.gov and login: as nlmpubs. The index file in the "bibs" directory provides information on the bibliographies available. Use of funds for printing this periodical has been approved by the Director of the Office of Management and Budget through September 30, 1994. COMMUNITY-BASED HEALTH CARE MODELS The 1993 NIH Revitalization Act created a new National Information Center on Health Services Research and Health Care Technology (NICHSR) at the National Library of Medicine. The overall goals of the NICHSR are: to make the results of health services research readily available to health care practitioners, health care administrators, health policy makers, payers, and the information professionals who serve these groups; to improve access to information needed by the creators of health services research; and to contribute to the information infrastructure needed to foster patient record systems that can produce useful health services research data as a by-product of current health care. One area specifically targeted in this program is the development and dissemination of information on health models, such as models of community-based health care. Community-based health care is focused on primary rather than institutional or acute care. Much of this care is provided by nurses and physicians assistants. The National Institute for Nursing Research (NINR) convened the Second Conference on Research Priorities in Nursing in November of 1992. During this conference, the development and testing of community-based nursing models designed to promote access to and utilization of quality health services in rural and other underserved populations was identified as a first priority of the National Nursing Research Agenda (NNRA). NINR convened The Priority Expert Panel on Community Based Nursing on December 13-15, 1993 and with the assistance of the NICHSR produced this bibliography to inform panel members about relevant literature. This bibliography contains citations to very selective models of community-based health care. Most models are in use in the United States. The citations are grouped by subject area, including: access to health care, community health, community health models, health promotion, models of care delivery, nursing centers, primary care, transitional care, rural and urban health, and vulnerable populations. As a subtext, most citations concern some facet of nursing. The selected references are to monographs and journal articles in English and for the most part are limited to the United States. Citations are arranged by subject and appear under only one topic. Abstracts have been included when available. Reprint permission has been obtained from the publishers concerned. When publishers requested specific copyright statements, they have been included at the end of the abstract. SEARCH STRATEGY A variety of online databases are usually searched in preparing bibliographies in the CBM series. To assist you in updating or otherwise manipulating the material in this search, the strategy used for the NLM's MEDLINE database is given below. Please note that the search strategies presented here differ from individual demand searches in that they are generally broadly formulated and irrelevant citations edited out prior to printing. SS 1 = ALL NURS: OR ALL COMMUNIT: SS 2 = PRIMARY HEALTH CARE OR PHYSICIANS, FAMILY OR FAMILY PRACTICE OR PREVENTIVE HEALTH SERVICES OR HEALTH PROMOTION OR HEALTH SERVICES FOR THE AGED OR HEALTH SERVICES ACCESSIBILITY SS 3 = ALL UNDERSERV: OR ALL URBAN: OR ALL RURAL: OR ALL POOR: OR ALL POVERTY: OR ALL MINORIT: OR ALL BLACKS OR ALL HISPANIC: OR MEXICAN AMERICANS OR ALL ELDERLY: OR AGED OR MEDICALLY UNINSURED OR MEDICAL INDIGENCY OR SOCIOECONOMIC FACTORS OR HOMELESS PERSONS OR ALL TRANSCULTURAL SS 4 = ALL PILOT: (TW) OR ALL MODEL: (TW) OR ALL INNOVAT: (TW) OR PROGRAM EVALUATION OR RESEARCH OR RESEARCH DESIGN SS 5 = 1 OR 2 SS 6 = 3 OR 4 SS 7 = 5 AND 6 SS 8 = 7 AND NOT FOR (LA) GRATEFUL MED To make online searching easier and more efficient, the Library offers GRATEFUL MED, microcomputer-based software that provides a user-friendly interface to most NLM databases. This software was specifically developed for health professionals and features multiple choice menus and "fill in the blank" screens for easy search preparation. GRATEFUL MED runs on an IBM PC (or IBM-compatible) with DOS 2.0 or a Macintosh, and requires a Hayes (or Hayes-compatible) modem. It may be purchased from the National Technical Information Service in Springfield, Virginia, for $29.95 (plus $3.00 per order for shipping). For your convenience, an order blank has been enclosed at the back of this bibliography. SAMPLE CITATIONS Citations in this bibliographic series are formatted according to the rules established for Index Medicus*. Sample journal and monograph citations appear below. Note also that a colon (:) may appear within an author's name or article title. The NLM computer system automatically inserts this symbol in the place of a diacritical mark. Journal Article: Author Article Title Campinha-Bacote J. Community mental health services for the underserved: a culturally specific model. Arch Psychiatr Nurs 1991 Aug;5(4):229-35. Abbreviated Journal Title Date Volume Issue Pages Monograph: Author/Editor Title Burgel BJ. Innovation at the work site: delivery of nurse-managed primary health care services. Washington: American Nurses Pub.; 1993. 40 p. Place of Publication Publisher Date Total Pages _________________________________ *For details of the formats used for references, see the following publication: Patrias, Karen. National Library of Medicine recommended formats for bibliographic citation. Bethesda (MD): The Library; 1991 Apr. Available from: NTIS, Springfield, VA; PB91-182030. TABLE OF CONTENTS Access to Health Care Advanced Nursing Practice Community Health Community Health Model Health Promotion Models of Care Delivery Nursing Centers Primary Care Rural Health Transitional Care Urban Health Vulnerable Populations ACCESS TO HEALTH CARE Campinha-Bacote J. Community mental health services for the underserved: a culturally specific model. Arch Psychiatr Nurs 1991 Aug;5(4):229-35. Underutilization of community mental health services by minorities has been an ongoing concern in the field of mental health. Many agencies are mainstream and ethnocentric in their services to culturally diverse clients, resulting in color-blind treatment approaches. During the era of civil rights, the concept of difference was used to exclude groups of individuals, families, and communities from access to resources. However, ethnicity does matter and make a difference. This article will address the need for culturally relevant services for African-American clients with the dual diagnosis of substance abuse and mental illness. The intent is to provide mental health care providers with a culturally specific model that will render culturally relevant and culturally competent services to individuals from diverse cultural backgrounds. Chermak GD. A global perspective on disability: a review of efforts to increase access and advance social integration for disabled persons. Int Disabil Stud 1990 Jul-Sep;12(3):123-7. Disability has emerged as a major public health problem worldwide, common to nations presenting disparate levels of socioeconomic development. Failure to integrate social welfare programmes within national development planning exacerbates difficulties arising from limited resources, with a disproportionate impact on disabled persons and other vulnerable groups. Such policy failure allows flagrant inequalities and social injustice to persist. Strategies are emerging, however, that are useful for solving common international problems. Community-based disability prevention and rehabilitation is one emerging solution that has attracted considerable attention worldwide, including in the United States. Following a review of global estimates of disability, which reveal the magnitude of the problem and provide background information for this report, I will summarize major international initiatives designed to prevent disability and ensure comprehensive rehabilitation for disabled persons. I will also analyse the relationships between health, socioeconomic development, and disability. Finally, I will describe community-based rehabilitation, an innovative approach evolving from the World Health Organization's Global Strategy for Health for All by the Year 2000, an approach with potential to eliminate barriers to equal opportunities and social integration for disabled persons. Copyright Taylor and Francis, Inc. Washington, D.C. Reprinted with permission. Haworth MJ. Hospital-based community outreach to medically isolated elders. The nurse gerontologist is a key link in this health care delivery system in Wisconsin. Geriatr Nurs (New York) 1993 Jan-Feb;14(1):23-5. The development of a hospital-based community outreach nursing program has been beneficial for St. Mary's Hospital in several ways. The outreach program has served a community need in that many elderly persons who were previously medically isolated have now been located and linked to the health care delivery system. The outreach program has reinforced the hospital's presence and leadership role in the community through its work with the elderly population. The hospital is seen as being committed to bringing health care services to its elderly neighbors. Through the establishment and coordination of health care services to previously isolated and unconnected elderly persons, there has been a broadened revenue base for hospital operations. The outreach program also supports the mission, philosophy, and objectives of the Daughters of Charity. The efforts of this outreach program have shown that high-quality, accessible, and coordinated care for the elderly population may be obtained using a nurse gerontologist. Efforts to expand the market share of elderly persons by the hospital has continued through the development of other innovative health programs, resources, and services. Hospital administrators need to develop programs and services that effectively utilize limited health care dollars and resources to improve the quality of health care within the community. Morrison C. Delivery systems for the care of persons with HIV infection and AIDS. Nurs Clin North Am 1993 Jun;28(2):317-33. HIV infection and AIDS are pathologic conditions that more than any other disease require the concerted, cooperative efforts of the health care profession and the community. This article discusses the development of delivery systems for the care of persons with HIV infection and AIDS, highlights what systems have been successful, and indicates the areas in which further research and development are needed. Topics discussed include the costs of care; identifying and meeting the specific health care needs of the HIV-infected population; and long-term, community-based, hospice, and hospital care. ADVANCED NURSING PRACTICE Fullerton JT, Palinkas L, Cavero C. Nurse- midwifery services in one multi-ethnic, underserved community. J Health Care Poor Underserved 1991 Fall;2(2):293-306. Through a nurse-midwifery service in a mixed urban and rural agricultural community, we compared maternal risk factors, prenatal care, labor and delivery, and adverse birth outcomes in low-income Mexican-American Hispanic, white (Caucasian), and Southeast Asian women--a three-way analysis rarely reported in the literature. Southeast Asian women were older and had more children. Hispanic women bore children at a younger age. Both Southeast Asians and Hispanics made fewer prenatal visits than did Caucasian women, and used less analgesia and anesthesia during delivery. The incidence of Cesarean section (7.7 percent) and low birthweight (5.9 percent) was compared to local, state, and national reference statistics. Prospective case-controlled studies and cost/benefit analyses of nurse-midwifery services could yield more definitive information. But until more precise data are collected for birth certificates, these studies will be difficult. Haddad B. Report on the expanded role nurse project. Can J Nurs Adm 1992 Nov-Dec;5(4):10-7. Based on increasing patient acuity, shortage of adequately prepared nurses, universal funding cutbacks as well as reduction in the numbers of medical residents in Ontario, University Hospital in London embarked on a project to develop and expand the role of the nurse in 1988. Utilizing the project objectives as a framework, this paper summarizes the status after three years by describing the extent to which the objectives have been or are being met. Factors which support and factors which impede success are identified and plans for action are presented. Kuehnert PL. The public health policy advocate: fostering the health of communities. Clin Nurse Spec 1991 Spring;5(1):1-10. The community health clinical nurse specialist (CNS) is unique among CNSs in defining the client as a community of people. This nurse specialist operates in partnership with the community using policy development and policy advocacy in nursing interventions. These nursing interventions enable and empower communities to explore pathways to public policy change. Such changes include improving accessibility, availability, and affordability of health services, and changing social conditions found at the root of many health problems. A case study is presented to illustrate the application of this CNS role. Layzell S, McCarthy M. Specialist or generic community nursing care for HIV/AIDS patients? J Adv Nurs 1993 Apr;18(4):531-7. Improved management of HIV-related illness means that patients spend over 80% of their time in non-institutional settings. Most community-based health care in the United Kingdom is provided by primary health care teams: general practitioners and community nurses, with support from social workers. However, in many areas specialist HIV services have assumed responsibility for the care of HIV/AIDS patients, and primary health care teams have only played a marginal role. Our study examined patterns of community nursing for HIV/AIDS patients in one regional health authority, North-East Thames (NETRHA). Interviews with 77 people in seven health districts included community nurse managers, clinical nurse specialists (CNS) HIV/AIDS and palliative care nurses. The appropriateness of different nursing models was assessed, taking into account the changing epidemiological and demographic profile of the disease, the influence of dedicated HIV funding, and the effect of recent British National Health Service reforms. Three models of care have developed in NETRHA: specialist HIV teams, individual CNS HIV/AIDS acting as a resource to generic staff, and care given by generic community nurses. Our work suggests that both generic community nurses and patients benefit from specialist input, and that this should be provided using CNSs HIV/AIDS in an advisory and facilitative capacity. Copyright Reprinted by permission of Blackwell Scientific Publications, Inc. Nelson-Conley CL. Role development of the clinical nurse specialist within the Indian Health Service. Clin Nurse Spec 1990 Fall;4(3):142-6. The clinical nurse specialist is employed in many health care facilities to improve patient care. One service unit of the Indian Health Service has expressed interest in the development of this role. At the present time, there are no advanced practitioners within this facility. Development, as well as implementation of the role, must be based on the cultural and health care needs of the Indian people. This paper discusses development of the role of perioperative clinical nurse specialist, based on personal experience, at a service unit providing health care to a large tribe of American Indians in the Southwestern United States. Examples of care incorporating cultural practices, are used to illustrate the practice of the perioperative specialist within the Indian Health Service. The nursing process is used to organize the development of the role. COMMUNITY HEALTH Applebaum RA, McGinnis R. What price quality? Assuring the quality of case-managed in-home care. J Case Manag 1992 Spring;1(1):9-13. Case managed community-based long-term care has now become an established component of the service delivery system in the United States. As case management has developed, it has gone through an evolutionary process. In the initial phase of case management, considerable attention was placed on gaining access to resources by the case manager. This article addresses issues of assuring the quality of case-managed care. It focuses on the current concerns and potential problems associated with evaluating the effectiveness of services arranged by case managers, and describes a model, developed in Ohio, to ensure the quality of care. In addition, it discusses the continued challenges for and costs of quality assurance and notes the difficulty of obtaining empirical data in the effort to assure quality. Copyright Springer Publishing Company, Inc., New York 10012. Used by permission. Bergen A. Case management in community care: concepts, practices and implications for nursing. J Adv Nurs 1992 Sep;17(9):1106-13. Case management has recently become a prominent issue in British community policy and practice, but one which, at the same time, has been subjected to a variety of interpretations. For this reason, it is considered useful to analyse it in terms of a framework embracing conceptual and operational components rather than within the more limiting confines of conventional definitions. A review, within this framework, of initial research projects suggests case management to be a viable mode of community care, with generally favourable outcomes. It also suggests a potentially significant role for community nurses as case managers, although several issues need to be considered when implementing these practices. Finally, a number of questions emerge which should be the focus of future research in the area. Copyright Reprinted by permission of Blackwell Scientific Publishing, Inc. Dineen K, Rossi M, Lia-Hoagberg B, Keller LO. Antepartum home-care services for high-risk women. J Obstet Gynecol Neonatal Nurs 1992 Mar-Apr;21(2):121-5. OBJECTIVE: To determine the scope of home-care services for pregnant women by addressing types of agencies, nursing personnel, and problems encountered. DESIGN: Descriptive study with survey questionnaire. SETTING: A sample of urban and rural settings throughout Minnesota. PARTICIPANTS: Nine private and 38 public agencies providing antepartum home-care services. MAIN OUTCOME: Data described clients, agencies, personnel, and services. RESULTS: Differences were reflected in the nursing skills and interventions used with high-risk pregnant women. Public agencies identified teenage pregnancy as the most frequent antepartum problem, while private agencies identified preterm labor. CONCLUSION: Results suggest a need to examine the scope of antepartum home-care services. Copyright J.B. Lippincott Co. Geis MJ. Differences in technology among subspecialties in community health nursing. J Community Health Nurs 1991;8(3):163-70. Interest in differentiating community health nursing from home health nursing has focused on theoretical models, concepts, and examinations of the historical origins and evolution of the roles. Although not usually included in the recent differentiation efforts, school and occupational health nursing traditionally have been considered important subspecialties of community health nursing. Utilizing an approach to technology developed by organizational researchers and focusing not on hardware and equipment, but on the characteristics of the raw materials and techniques employed, this study examined the differences among public health/community health, home health, school health, and occupational health on the three technological dimensions of uncertainty, instability, and variability. Survey data from nurses in the four areas (N = 40) were utilized. Results indicated that home health nursing differed significantly from the other groups on the dimensions of uncertainty and instability. Copyright Lawrence Erlbaum Associates, Inc. Haas DL. Historical overview of the development of family-centered, community-based, coordinated care in Michigan. Issues Compr Pediatr Nurs 1992 Jan-Mar;15(1):1-15. Caring for children with special health care needs (SHCN) is a challenge that has been faced with commitment and concern in this country. However, by the late 1970s, it was clear to some that an analysis of the efficacy of the existing structure of care was long overdue. As scrutiny of the current processes began to unfold, new and improved ideas were emerging throughout the United States. A continuous theme through that process was the need and desire to create care systems that were family-centered, aimed at coordinating care, and were close to the child and family's community. These activities provided a conceptual background from which Michigan began to redesign existing programs and develop new initiatives. Simultaneously, Michigan's experiences were influencing national efforts to create family-centered, community-based, coordinated care structures for children with SHCN. This article highlights key national efforts and individuals who influenced program development for children with SHCN in Michigan. In addition, specific family-centered efforts that occurred in the state since the early 1980s, and that continue to date, are described. Copyright Taylor & Francis, Inc. Washington, D.C. Reprinted with permission. Kivell PT, Turton BJ, Dawson BR. Neighbourhoods for health service administration. Soc Sci Med 1990;30(6):701-11. Health and social service administrators are increasingly realizing the importance of adopting a community or neighbourhood scale for the organisation and delivery of many different services. The concept of neighbourhood is an elusive one, yet it has been used for a number of planning purposes. This paper reviews the nature and utility of neighbourhoods and demonstrates the variety of territorial units used by different statutory agencies. The results of an empirical exercise in North Staffordshire are reported as an example of the practical issues involved. Neighbourhoods are identified with a view to being used for data collection, the delivery of health care services and the possible implementation of health forums. Copyright 1990, Elsevier Science Ltd. Kidlington, UK. Reprinted by permission. Kizer KW. Guidelines for community-based screening for chronic health conditions. Am J Prev Med 1991 Mar-Apr;7(2):117-20. Preventive measures for many chronic diseases depend upon identification of asymptomatic individuals who have the disease or who may be at risk for developing it. A screening biochemical test can identify such individuals. Mass screening for biochemical markers or risk factors for chronic conditions, especially for elevated serum cholesterol and blood glucose, has been advocated in recent years and has become increasingly common in various nonmedical community settings. Although generally well intentioned, such programs may fall short of their goals and may even be counterproductive. In recognition of the use of biochemical screening in nonmedical community settings, and in an attempt to make such efforts as productive as possible, the California Department of Health Services (CDHS) has developed state guidelines for these screening programs. These guidelines make recommendations regarding: (1) the criteria for judging the effectiveness of biochemical screening tests; (2) the qualifications and training of screening program staff; (3) the proper use and maintenance of equipment used in screening programs and other quality control measures; (4) referral procedures for persons with abnormal test results; and (5) the lawful implementation of screening programs. Optimally, as pointed out by these guidelines, all community-based screening programs should complement a larger health education or risk-reduction program that guarantees appropriate medical follow-up and management. Preventive medicine practitioners and organizations embarking on such activities should be familiar with the issues addressed by these guidelines and may find adherence to them useful in developing effective community screening programs. Kozlak J, Thobaben M. Treating the elderly mentally ill at home. Perspect Psychiatr Care 1992 Apr-Jun;28(2):31-5. Published erratum appears in Perspect Psychiatr Care 1992 Jul-Sep;28(3):18. Psychiatric home health nursing provides an emerging arena for treating elderly clients diagnosed with major mental disorders. Client autonomy is maintained, and treatment can be tailored to individual need. The authors describe the concept of home care for the elderly mentally ill and issues related to funding and providing services. To illustrate the broad scope of available nursing treatment for the elderly, three case studies of clients with diagnoses of anxiety/depression, schizophrenia, and bipolar disorder are discussed. Copyright Reprinted with permission, Nursecom, Inc. Kuhlman GJ, Wilson HS, Hutchinson SA, Wallhagen M. Alzheimer's disease and family caregiving: critical synthesis of the literature and research agenda. Nurs Res 1991 Nov-Dec;40(6):331-7. This paper is a synthesis of knowledge about Alzheimer's disease (AD) and AD family caregiving published over the last decade (approximately 1979-1990). While there has been an increase in the volume of scientific work in this area, methodological difficulties, unclear findings, and gaps, particularly with regard to inclusion of ethnic minority populations, persist. The current research priority on evaluating intervention programs represents a worthy direction, yet such a focus may be premature until basic knowledge builds on, extends, and transcends the foundation established in the past decade. Layzell S, McCarthy M. Community-based health services for people with HIV/AIDS: a review from a health service perspective. AIDS Care 1992;4(2): 203-15. Health services for people with HIV/AIDS have been mainly hospital based, but it is now recognized that much care can be provided outside hospitals. There are well documented problems in delivering care in the community to other client groups such as the elderly and the mentally ill, but there are particular difficulties with HIV/AIDS care. These stem in part from the clinical demands of AIDS-related illnesses, but also from the stigma associated with the disease. This review looks at three key areas of relevance to those planning community-based health services for people with HIV/AIDS. These are: the need for collaboration between the statutory and voluntary sectors; the need for co-ordination between providers at the point of service delivery; and whether care should be provided by generic or specialist providers. While certain universal principles apply, and are necessary to ensure a good standard of care, patterns of service delivery will inevitably vary according both to the local prevalence rates and the existing service infrastructure. There is more than one good model of care; all models must be flexible enough to deal with needs on an individual basis. Levine DM, Becker DM, Bone LR, Stillman FA, Tuggle MB 2d, Prentice M, Carter J, Filippeli J. A partnership with minority populations: a community model of effectiveness research. Ethn Dis 1992 Summer;2(3):296-305. This paper describes a community-based approach, including a partnership of an academic medical institution and a high-risk, urban, African-American population, directed at decreasing premature morbidity and mortality and enhancing health and functional status. The intervention approach is based on a model of community-based leadership and "ownership" of interventions and programs to enhance sustainability of effective approaches, and it follows specific stages to assure appropriate assessment and evaluation. Initial efforts were directed at the control of hypertension and were coordinated through decentralized mayor's stations in Baltimore, Maryland. This approach was successful in significantly enhancing control of hypertension and reducing related morbidity and mortality. Over time, an enhanced partnership has been coordinated through churches in the community and organized around a program entitled "Heart, Body, and Soul." Current efforts are directed at the major risk factors and preventable and/or controllable problems in the population, such as hypertension, smoking, obesity, diabetes, hyperlipidemia, and cervical and breast cancer. Key components include the training of neighborhood health workers to provide screening, counseling, monitoring, support, and follow-up; enhanced access to caretraining of high school students as health counselors and use of media to promote healthier life-styles. Norr KF, McElmurry BJ, Moeti M, Tlou SD. AIDS prevention for women: a community-based approach. Nurs Outlook 1992 Nov-Dec;40(6):250-6. Stoner MH, Magilvy JK, Schultz PR. Community analysis in community health nursing practice: the GENESIS model. Public Health Nurs 1992 Dec;9(4):223-7. A community-analysis strategy, GENESIS (general ethnographic and nursing evaluation studies in the state), is a comprehensive, holistic portrait of communities obtained through secondary analysis of existing data and qualitative methods. The GENESIS method is delineated and examples of studies are presented. To explicate the method and illustrate the findings, an aggregate-focused GENESIS study and two studies in which entire communities were the targets are compared and contrasted. Other defining concepts of nursing, such as caring and health, are redefined or explicated to make them congruent with the recognition that for community health nurses, the community is the client. Copyright Reprinted by permission of Blackwell Scientific Publications, Inc. Wieland D, Ferrell BA, Rubenstein LZ. Geriatric home health care. Conceptual and demographic considerations. Clin Geriatr Med 1991 Nov;7(4):645-64. This article has explored conceptual and demographic aspects of HHC and the distinction between formal and informal care. HHC for elderly persons is shown to be mainly an informal, familial activity with important formal professional, skilled, and unskilled components. Formal home health care in the United States has undergone a historic transformation with the rise of third-party payment as a principal, defining force and with demographic and epidemiologic transition of the general population. Recent national studies demonstrate that the principal population group receiving HHC services--the chronically ill, functionally limited, noninstitutionalized elderly--is growing in number and as a proportion of the group with home and community service needs. Although diverse formal service innovations are being explored to meet these growing needs, current involvement of medical professionals in formal HHC emphasizes relatively short-term, post-acute therapeutic and restorative care offered through Medicare-certified home health agencies. COMMUNITY HEALTH MODEL Kane RL, Illston LH, Miller NA. Qualitative analysis of the program of all-inclusive care for the elderly (PACE). Gerontologist 1992 Dec;32(6): 771-80. The innovative model of capitated acute and chronic care for nursing-home-eligible elderly persons, which was developed at On Lok in San Francisco's Chinatown and stresses using community care in lieu of institutional care, has been replicated at eight sites around the country. The early experience in developing these sites tests the extent to which the principles of this approach, based on day health care, can be reproduced in a variety of other settings. Four of the eight sites have begun formal capitated careenrollment has been less active than anticipated, apparently due to reluctance to change physicians and resistance to day care. Copyright The Gerontological Society of America. Marcenko MO, Smith LK. The impact of a family-centered case management approach. Soc Work Health Care 1992;17(1):87-100. Two urban programs of family-centered case management services were established for families of children with both a developmental disability and a chronic health condition. These are children who present significant caregiving demands due to the long-term and severe nature of their disabilities. Thirty-two mothers were interviewed within the family's first month in the project and reinterviewed approximately one year later. The results indicate that more families received respite care, nursing services, training in the care of the child, educational services and transportation to school at follow-up than had been receiving those services at baseline. However, families still indicated high service needs for recreational activities, life planning, regular day care, legal services, and speech therapy at follow-up. Mothers indicated that program services were helpful in obtaining services, financing, information, support, and advocacy. Although maternal life satisfaction improved with program participation, non-handicapped siblings continued to have difficulties coping. The model employed is described and the practice and policy implications of the findings discussed. Copyright By the Haworth Press, Inc. All rights reserved. Reprinted with permission. McCool WF, Susman EJ. The life span perspective: a developmental approach to community health nursing. Public Health Nurs 1990 Mar;7(1):13-21. Following the nursing theorists' tradition of using an interdisciplinary approach to community health model building, the concepts of the life span perspective on human development were applied to the practice of community health nursing. As with the perception of individual development from this perspective, communities are viewed as evolving over time, with changes occurring across levels of influence -- human, societal, historical, and cultural. These levels are interdependent, and factors from any one or more can affect the growth and functioning of the community. Implied in this interdependence is the ability not only to intervene in a community's development, but to go beyond this and recognize that a community has a degree of control over its own development. To be accurate and thorough in working with communities, the community health nurse who takes a life span perspective must be cognizant of the fact that communities do exist in a continual, multilevel, interactive manner that develops through time. Demonstrating the practical use of this perspective, a model for the assessment phase of the nursing process as applied to community study was developed. A pilot study was performed using this model, and initial results suggest that taking a life span perspective toward community health is both valid and practical, and warrants further scholarly investigation. Copyright Reprinted by permission of Blackwell Scientific Publications, Inc. Olds DL, Henderson CR Jr, Phelps C, Kitzman H, Hanks C. Effect of prenatal and infancy nurse home visitation on government spending. Med Care 1993 Feb;31(2):155-74. A completed series of reports on a randomized trial (N = 400) indicated that, in contrast to comparison services, prenatal and infancy nurse home visitation improved a wide range of maternal and child health outcomes among poor, unmarried, and teenaged women bearing first children in a semirural county in upstate New York. Eighty-nine percent of the sample was white, and all analyses focused on this group. In this article, an analysis of the net cost of the home-visitation program from the perspective of government spending is presented. The average per-family cost of the program in 1980 dollars was $3,246 for the sample as a whole, and $3,133 for low-income families. Treatment differences in government expenditures for Aid to Families with Dependent Children, Food Stamps, Medicaid, and Child Protective Services, minus tax revenues due to maternal employment (also expressed in 1980 dollars), were conceived as government savings. By the time the children were 4 years of age, government savings were $1,772 (95% confidence interval [CI]: -$557, $4,102) for the sample as a whole, and $3,498 (95% CI: $569, $6,427) for low-income families. Within 2 years after the program ended, after discounting, the net cost of the program (program costs minus savings) for the sample as a whole was $1,582 per family. For low-income families, the cost of the program was recovered with a dividend of $180 per family. Copyright J.B. Lippincott Co. Williams ME, Williams TF. Evaluation of older persons in the ambulatory setting. J Am Geriatr Soc 1986 Jan;34(1):37-43. This report provides a comprehensive description of an established outpatient geriatric consultation service. The basic objectives of the service are to promote health and to prevent or minimize disability. The consultation service uses a multi-disciplinary team with core participants from medicine, nursing, and social work and is based in a setting where a wide range of specialty consultants and ancillary services are available. A detailed description of 131 individuals who received geriatric consultations during a one-year period is provided. Despite a substantial burden of disability, most older persons after the consultation process were able to continue living in their own preferred setting. The degree to which the geriatric consultation service contributed to these favorable outcomes is currently being evaluated through a randomized clinical trial. Copyright Reprinted with permission of the American Geriatrics Society. HEALTH PROMOTION Aguirre-Molina M, Molina CW. Ethnic/racial populations and worksite health promotion. Occup Med 1990 Oct-Dec;5(4):789-806. This chapter describes the health characteristics and health risks of ethnic-racial populations and the implications for planning and delivering health promotion programs at the worksite. Special consideration is given to occupational stratification, which separates these groups from their white counterparts, thus requiring special attention. Guidelines are given for designing culturally appropriate worksite health promotion programs. Bly JL, Jones RC, Richardson JE. Impact of worksite health promotion on health care costs and utilization. Evaluation of Johnson & Johnson's Live for Life program. JAMA 1986 Dec 19;256(23):3235-40. This study explores the relationship between exposure to a comprehensive worksite health promotion program and health care costs and utilization. The experience of two groups of Johnson & Johnson employees (N = 5192 and N = 3259) exposed to Live for Life, a comprehensive program of health screens, life-style improvement programs, and worksite changes to support healthier life-styles, was compared with that of a control group (N = 2955) over a five-year period. To account for baseline differences, analyses of covariance produced adjusted means for inpatient hospital costs, admissions, hospital days, outpatient costs, and other health costs. Mean annual inpatient cost increases were $43 and $42 for two Live for Life groups vs $76 for the non-Live for Life group. Live for Life groups also had lower rates of increase in hospital days and admissions. No significant differences were found for outpatient or other health care costs. Copyright 1986, American Medical Association. Eakin JM, Maclean HM. A critical perspective on research and knowledge development in health promotion. Can J Public Health 1992 Mar-Apr;83 Suppl 1: S72-6. The paper addresses four issues that pervaded conference deliberations: the relevance of qualitative approaches to research, the importance of community participation in the research process, the need to broaden the disciplinary base of health promotion, and the possibilities for a critical research perspective. The paper suggests why the idea of qualitative methods is so appealing to health promotion researchers, and what may prevent such methods from living up to the expectations held of them. The emphasis on community participation in research expresses an attempt to make research more relevant and accountable, but it also may inhibit the theoretical grounding of research, and create strain between pragmatic and scientific interests. The field of health promotion is inherently multidisciplinary, but it remains unclear if and how different disciplines can be effectively combined or integrated. The relative absence of critical thought at the conference is noted, and the authors argue that a critical perspective is needed in both "research of" and "research for" health promotion. Palank, CL. Determinants of health promotive behavior: a review of current research. Nurs Clin North Am 1991 Dec;26(4):815-32. The determinants of health promotive behaviors are proposed as individual cognitive-perceptual factors, modifying factors, and direct cues to action. Although most perceptual factors have received empirical support for lifestyle indexes and singular behaviors such as exercise and nutritional activities, there remains a need to explore the impact of other factors that influence specific singular behaviors. Many proposed factors such as individual health definition, societal situations, biologic characteristics, and perceived benefits have not been studied extensively. Until further research is conducted on a combination of proposed individual perceptions and modifying factors, explicit conclusions for nursing implications remain theoretical. Rogers J, Grower R, Supino P. Participant evaluation and cost of a community-based health promotion program for elders. Public Health Rep 1992 Jul-Aug;107(4):417-26. There is little information on how best to provide health promotion and disease prevention services to elderly persons. This paper reports participants' perceptions of the effectiveness of a health promotion program consisting of health education classes and case management services. A single- group, posttest only design was used for the county-wide program, which operated independent of participants' primary care physicians. Each person received a thorough screening evaluation, was invited to health education classes, and was assigned a case manager for a 2-year health promotion period. Community residents 64-71 years of age were recruited; 475 entered the study, and 378 (79.6 percent) completed the followup evaluation interview. Only one-third of the participants attended at least one class, but a majority of those attending each class rated it very or extremely effective in increasing knowledge. To determine the effectiveness of the case managers, each participant identified the three health problems that were of greatest concern to him or her and indicated which of these priority problems were discussed with the case manager. Discussion with the case manager was significantly associated with continuing to see a personal physician for the problem, following the physician's recommendations, the problem's being under control, and the problem's improving over the 2-year followup. The classes and case management services benefited the participants who used them. How to best deliver these services to the target group needs further study. Shea S, Basch CE, Lantigua R, Wechsler H. The Washington Heights-Inwood Healthy Heart Program: a third generation community-based cardiovascular disease prevention program in a disadvantaged urban setting. Prev Med 1992 Mar;21(2):203-17. The Washington Heights-Inwood Healthy Heart Program (WHIHHP) is part of the New York State Healthy Heart Program, which comprises eight community-based programs in different areas of the state. WHIHHP is directed at a population of approximately 200,000 people, predominantly Hispanic and of low socioeconomic status, living in northern Manhattan in New York City. The initial 3 years of experience are presented. Six potential barriers to diffusion of the community-based disease prevention model in disadvantaged inner city communities are discussed: (a) issues of scale and complexity; (b) adaptation of this model to a "community" without geopolitical boundaries or infrastructure; (c) linguistic and cultural diversity; (d) competing problems; (e) the role of evaluation; and (f) sustainability of the program in a poor community. Strategies for addressing obstacles to model adoption are also described, including program legitimization, building program infra-structure, setting realistic expectations, focusing on one risk factor at a time, defining target population segments, and emphasizing a small number of communication channels. Finally, research issues related to the diffusion of the community-based model are discussed, specifically: (a) Does the model work in disadvantaged urban settings? (b) What are the program effects on social class gradients for risk factors? (c) What are the barriers to program adoption in such settings? (d) What changes in the model will facilitate adoption in such settings? (e) What are the best methods for conducting formative evaluation in such programs? (f) What is the best way to select communities that may be ready to adopt the model? Our initial experience implementing this model in a disadvantaged urban setting supports the feasibility of model adoption. Unanswered questions about efficacy in such settings and regarding research issues related to model diffusion will require additional research investment. Copyright 1992 Academic Press, Inc. MODELS OF CARE DELIVERY Albrecht M, Goeppinger J, Anderson MK, Boutaugh M, Macnee C, Stewart K. The Albrecht nursing model for home health care: predictors of satisfaction with a self care intervention program. J Nurs Adm 1993 Jan;23(1):51-4. Satisfaction with a self-care intervention program was evaluated through this quantitative study of arthritis clients at home. The results indicate that the clients were highly satisfied with the intervention. In this era of consumer satisfaction with their care, nurse administrator's knowledge of which interventions are satisfying is important for staff development and case management in the community. Copyright J.B. Lippincott Co. Albrecht MN. The Albrecht nursing model for home health care: implications for research, practice, and education. Public Health Nurs 1990 Jun;7(2): 118-26. Home health care has become increasingly popular with consumers. Despite this movement of care away from the hospital, the literature does not contain a comprehensive nursing model of home health care. The need for a model to guide nursing research and ultimately, nursing practice and education is apparent. Four health service delivery models are available to be applied to home health care nursinghowever, analysis of all four demonstrates a need for one specific to home care nursing. Copyright Reprinted by permission of Blackwell Scientific Publications, Inc. Albrecht MN. Home health care: reliability and validity testing of a patient-classification instrument. Public Health Nurs 1991 Jun;8(2):124-31. The purposes of this methodologic, descriptive, correlation study were to assess the reliability and validity of the Easley-Storfjell (ES) patient- classification instrument for home care, and determine to what extent it was useful in a large, hospital-based home health care setting. A model for home health care developed by the investigator was used. Interrater reliability and concurrent validity were established by four nurse-raters using a random sample. Nonparametric bivariate correlational analysis demonstrated that the ES instrument was both reliable and valid at a significant level. In addition, there was agreement between the overall ES category rating and rater frequency of home visits. Intrarater reliability for each of the four nurse-raters on a random sample was at a significant level. The results of this study have important implications for home health care agencies providing care to chronically ill patients. Copyright Reprinted by permission of Blackwell Scientific Publications, Inc. NURSING CENTERS Barger SE. Academic nursing centers: a demographic profile. J Prof Nurs 1986 Jul-Aug;2(4):246-51. In order to identify academic nursing centers, a questionnaire was sent to the dean or director of all 427 schools or colleges of nursing with National League of Nursing (NLN)-accredited baccalaureate programs. Of the 331 schools responding, 51 had academic nursing centers. Demographic data were obtained, including location, affiliation, size of the school, degrees offered, and presence of other practice facilities. According to the data, the school operating a nursing center is most often a public university or college, but is not part of an academic health science center. It offers a master's degree in nursing, and may have a doctoral program. The typical school is large, with more than 36 faculty members and more than 200 junior and senior students. Its administrative policies probably do not support faculty practice, but it may be more supportive than its counterparts without nursing centers. The 51 academic nursing centers are listed, and a review of the literature is presented. The author discusses the need for further research to evaluate the centers' success in meeting their goals of providing student experience, faculty practice, research, and community service. Kreidler MC, Conrad MA. A study of clients' perceived needs in a nursing center. J Nurs Care Qual 1992 Oct;7(1):57-63. Lenz CL, Edwards J. Nurse-managed primary care. Tapping the rural community power base. J Nurs Adm 1992 Sep;22(9):57-61. Involving community members into plans and projects is especially salient in initiating and maintaining nurse-managed centers. Nowhere is community involvement more crucial than in establishing a nursing practice in an isolated rural setting. The authors share their first-hand experiences in community interaction in establishing the state-funded health center. Copyright J.B. Lippincott Co. Riesch SK. Nursing centers: an analysis of the anecdotal literature. J Prof Nurs 1992 Jan-Feb;8(1):16-25. The anecdotal literature is reviewed to analyze the development and implementation of nursing centers and to make recommendations for the future. Definitions, historical developments, and services provided are reviewed and a conceptual categorization is suggested. To realize the potential of nursing centers as viable service delivery models, their leaders are urged to develop objective outcomes, test the scientific adequacy of the nursing care delivered, develop affiliations with traditional health care delivery systems, and require nursing students to rotate through these centers as part of their undergraduate and selected graduate experience. Riesch SK. A review of the state of the art of research on nursing centers. NLN Publ 1990 Sep;(41-2281):91-104. PRIMARY CARE Burgel BJ. Innovation at the work site: delivery of nurse-managed primary health care services. Washington: American Nurses Pub.; 1993. 40 p. Developed by a task force of the American Nurses Association and the American Association of Occupational Health Nurses: Task Force on Nursing's Agenda for Health Care Reform. Crosby F, Ventura MR, Feldman MJ. Future research recommendations for establishing NP effectiveness. Nurse Pract 1987 Jan;12(1):75-6, 78-9. An information synthesis was conducted to examine nurse practitioner effectiveness as substantiated in existing literature. After an extensive computerized and manual search of the literature, 248 documents judged by staff to be relevant to the topic were reviewed by a content-area expert (N = 11 members), and a methodology expert (N = 8 members). Experts had been chosen on the basis of multiple nominations from an extensive national survey of professional nurses in leadership positions. Upon completing the respective reviews, experts identified key areas in support of NP effectiveness that had not been established or clarified in existing literature. A summary and discussion of the experts' recommendations for future studies in support of nurse practitioner effectiveness are presented. Copyright 1987, Elsevier Science Publishing Co., Inc. Reprinted by permission. Fenton MV, Rounds LR, Anderson ET. Combining the role of the nurse practitioner and the community health nurse. An educational model for implementing community-based primary health care. J Am Acad Nurse Pract 1991 Jul-Sep;3(3):99-105. With increasing health care costs, public health agencies and other institutions have a critical need for master's-prepared nurses who can provide health care for common health problems of individuals and families but also assess, plan, intervene, and evaluate the needs of communities. This article describes the development of a nursing master's degree program to meet that need which combines the traditional roles of the nurse practitioner and the community health nurse. The program is based on the global concept of primary health care as defined by the World Health Organization, which includes more emphasis on economic, political, environmental, and social factors. Copyright J.B. Lippincott Co. Ferguson MG, Berkeley L, Fourcher L, Guyton B, Reiner LR. Health Care Linkage Project: improving access to care. Henry Ford Hosp Med J 1992;40(1-2):9-12. The primary objective of the Health Care Linkage Project, funded by a grant from the Chicago Community Trust, is to develop, implement, and evaluate a primary health care linkage network within the city of Chicago that creates formalized linkages between community health centers, the Chicago Department of Health clinics, and hospitals. Six linkage networks are currently operational, with an additional two sites phased in during 1991. The success of the pilot project has been demonstrated by hundreds of patients receiving primary care and ancillary services on a more timely basis, by greater coordination between the public and private sector, by cost-savings to both patients and providers through reducing inappropriate use of services, and by a variety of spin-off projects which have improved the quality and accessibility of services. A second important objective is the development of a Health Care Linkage Manual that describes the practical experience and lessons gained from the linkages, the status of comparable arrangements in other U.S. cities, replicability of the linkage models, and recommendations for policy changes which will make linkages more effective. Copyright 1992 Henry Ford Hospital Medical Journal. Goodman RM, McLeroy KR, Steckler AB, Hoyle RH. Development of level of institutionalization scales for health promotion programs. Health Educ Q 1993 Summer;20(2):161-78. This study was conducted to test an instrument for measuring the level of institutionalization (LoIn) of health promotion programs. Institutionalization occurs when a program becomes an integral part of an organization, and the LoIn instrument is a beginning effort to measure the extent of program integration into organizations. The instrument is based on theory that holds that organizations are composed of production, maintenance, supportive, and managerial subsystems. Institutionalization occurs when a program becomes imbedded into these subsystems. A questionnaire designed to test this construct was mailed to 453 administrators in 141 organizations that operate health promotion programs. Based on 322 usable responses (71%), a confirmatory factor analysis was conducted. The results support the hypothesis of an eight-factor model: four factors concern how routinized the program was in each subsystem and four factors concern the degree of program saturation within each subsystem. Correlations of the eight factors with the number of years the programs had been in operation, and managers' perceptions of program permanency, indicated that the four routinization factors were more highly correlated with program longevity than the four niche saturation factors, and the niche saturation factors were more highly correlated with managers' perceptions of program permanence than the routinization factors. The instrument, which is available from the authors, may be used as both a research instrument and a diagnostic tool in assessing the institutionalization of health promotion programs. Martinez NH, Schreiber ML, Hartman EW. Pediatric nurse practitioners: primary care providers and case managers for chronically ill children at home. J Pediatr Health Care 1991 Nov-Dec;5(6):291-8. A new role has been developed for pediatric nurse practitioners that is home based and provides primary care and case management for chronically ill children. In a pilot program at Children's Hospital and Health Center in San Diego, pediatric nurse practitioners address the complex needs of chronically ill children who require comprehensive care, education, psychosocial support, and coordination of services. This article describes the population, program, and expanded role for PNPs, emphasizing case management, management of chronic illness, minor illnesses, and management of well child care. Clinical impressions of the benefits of the role to the child and family are presented. Copyright Reproduced with permission from Mosby-Year Book, Inc. McElmurry BJ, Swider SM, Norr K. A community- based primary health care program for integration of research, practice, and education. NLN Publ 1991 Jun;(15-2398):77-90. Moore GT. The case of the disappearing generalist: does it need to be solved? Milbank Q 1992;70(2):361-79. The proportion of generalist physicians in the United States has declined steadily over 50 years, bringing it to the lowest percentage of trained primary care physicians of any developed country; the trend toward subspecialization is accelerating. Many analysts believe this imbalance between generalists and subspecialists to be a major cause of America's high health care costs, heavy dependence on biotechnology, and consumer dissatisfaction. Others argue that subspecialists can provide excellent primary care services, and the decrease in the number of generalists is not a problem. Three contrasting views on the implications of this trend state that today's generalists are an important and scarce resource that must be bolstered that subspecialists can replace generalists as providers of primary care; and that the free market will determine the best manpower mix. A final view, on the marketplace option, posits that generalism will not recover until it creates a vital, and unique, role in handling the primary care challenges of the twenty-first century. These competing viewpoints are used to clarify assumptions underlying our major policy options in the arena of health manpower. Murata JE, Patrick Mace J, Strehlow A, Shuler P. Disease patterns in homeless children: a comparison with national data. J Pediatr Nurs 1992 Jun;7(3): 196-204. Although homeless children have increased in numbers as poverty has become feminized, minorities have become poorer, and low-income housing has become less accessible, little is known of their health problems. This study compared the health problems of a group of uninsured and homeless children visiting a free, nurse-managed, primary care clinic on Los Angeles' Skid Row with data from children's primary care visits to pediatricians and general and family physicians sampled in the National Ambulatory Medical Care Survey. Diagnoses were classified into the following health service categories: (a) acute, (b) communicable, and (c) chronic disease(d) preventive and (e) injury care. Comparisons indicated that services to homeless children differed significantly from reimbursed services in the national sample in all categories except chronic disease. Demographic analysis indicated that homeless children were predominantly Hispanic Americans. When data from Hispanic children were examined, the pattern of differences between the homeless and National Ambulatory Medical Care Survey diagnostic categories persisted. This study shows the variations in nursing care which a group of high-risk, severely impoverished, uninsured children require. Padula CA. Self-care and the elderly: review and implications. Public Health Nurs 1992 Mar;9(1):22-8. Self-care is the most predominant and basic form of primary care, yet research in the area, particularly with respect to the elderly, has been minimal. As a result, despite the breadth of the self-care movement, very little is precisely known and under-stood about it. Diminished functional health status is the major cause of loss of independence. Self-care is conceptualized as an important strategy in maintaining functional health. Copyright Reprinted by permission of Blackwell Scientific Publications, Inc. Pinn-Wiggins VW. Comments from the National Medical Association concerning a "white paper" on proposed strategies for fulfilling primary care manpower needs. J Natl Med Assoc 1990 Apr;82(4):245-8. The NMA has long had the participation and leadership of those in primary care and those who practice in medically underserved or medically indigent areas. We, therefore, are most supportive of the objectives and goals you have presented. We have offered suggestions to strengthen your "White Paper" by emphasizing the vital nature of the current and future role of primary health care delivery; by stating the effects that changes in physician reimbursement, especially utilizing the Relative Value Scale, will have on the expectations of those who are considering primary care by continuing to offer scholarship assistance and loan forgiveness to those who are willing to commit during their medical education to a primary care career through the NHSCby making a priority the effort to recruit older physicians by providing well-defined incentives, including liability relief and by emphasizing the continued recruitment, retention, and encouragement of minority and disadvantaged applicants entering health care careers and stressing the support they must receive to be able to afford to practice in underserved areas. The National Medical Association welcomes the chance to undertake any collaborative efforts which may aid our mutual missions. Therefore, we are willing to assist you in helping to solve the critical need for primary care physicians in medically underserved communities. Spitzer WO, Sackett DL, Sibley JC, Roberts RS, Gent M, Kergin DJ, Hackett BC, Olynich A, Hay WI, Lefroy G, et al. The Burlington randomized trial of the nurse practitioner. 1971-2. J Am Acad Nurse Pract 1990 Jul-Sep;2(3):93-9. From July 1971, to July 1972, in a large suburban Ontario practice of two family physicians, a randomized controlled trial was conducted to assess the effects of substituting nurse practitioners for physicians in primary-care practice. Before and after the trial, the health status of patients who received conventional care from family physicians was compared with the status of those who received care mainly from nurse practitioners. Both groups of patients had a similar mortality experience, and no differences were found in physical functional capacity, social function or emotional function. The quality of care rendered to the two groups seemed similar, as assessed by a quantitative "indicator-condition" approach. Satisfaction was high among both patients and professional personnel. Although cost effective from society's point of view, the new method of primary care was not financially profitable to doctors because of current restrictions on reimbursement for the nurse-practitioner services. [1965-1990: 25th anniversary of nurse practitioners. A classic manuscript reprinted in celebration of 25 years of progress.] Copyright J.B. Lippincott Co. Wright RA. Community-oriented primary care. The cornerstone of health care reform. JAMA 1993 May 19;269(19):2544-7. The current high-cost health care delivery system, which places greater emphasis on acute hospital care than on community-based primary and preventive care, is no longer viewed by policymakers, politicians, and the American public as the ideal model for organizing and providing health care services. Americans want change; however, politicians are responding with a barrage of disjointed finance and cost-containment proposals that fail to address the organization and provision of health care services. Nevertheless, to adequately address problems of cost, access, and quality, reform proposals will need to consider delivery models that create a balance between medical care and health care, between public health and personal health services, and between curative and preventive care. The community-oriented primary care model and the discipline of community and socially responsive medicine is a process for making a health care system more rational, accountable, appropriate, and socially relevant to the public. Consequently, this model, which is now at a pivotal point in its evolution, may serve as a paradigm for reforming the organization and provision of health care services in America. Copyright 1993, American Medical Association. RURAL HEALTH Bigbee JL. The uniqueness of rural nursing. Nurs Clin North Am 1993 Mar; 28(1):131-44. Rural nursing is a unique and challenging field of nursing that requires a "special breed" of nurse that is committed to high quality, comprehensive care at the individual, family, and community levels. The unique characteristics of rural nursing include close interaction with the community, a truly generalist approach, and increased autonomy, cohesiveness, and community visibility. This area of specialty practice requires nurses to be highly competent and well-prepared in all aspects of professional practice. Certainly, the demands of rural nursing are great, as are the benefits. Rural nursing can indeed be the essence of what nursing should be. Boettcher JH. Promoting maternal infant health in rural communities. The Rural Health Outreach Program. Nurs Clin North Am 1993 Mar;28(1):199-209. RHOP is a nurse-managed community-based program that uses a variety of approaches to reduce infant mortality and improve maternal child health. In a rural area, representative of much of the rural South, which has a persistent record of poor maternal-child outcomes, the program is using university and community resources to make a difference. The goal is to empower the community to help it help itself using all the available resources. The initial outcome data indicate that these positive changes are happening and can be the site for future activities by those in the community as well as the university. Future plans include involving more departments at the university in the program and expanding services to three additional counties. Graduate students and faculty are becoming interested in conducting research using RHOP activities as a base, and future grants are being considered to expand into new areas such as substance abuse and cancer prevention. Buckwalter KC, Smith M, Zevenbergen P, Russell D. Mental health services of the rural elderly outreach program. Gerontologist 1991 Jun;31(3):408-12. This paper describes an elderly outreach program (EOP) designed to identify and provide mental health services to the rural elderly. The project integrates a variety of health, mental health, and human service agencies in the planning and delivery of services. Five referral sources are identified and described as well as the assessment, treatment, and referral process. Outcomes are discussed in terms of: characteristics of persons served, ability of the project to identify and deliver mental health services, treatment effectiveness, and cost effectiveness of the project. The EOP seems to have prevented an increase in need for mental health care among Iowans that might have occurred in the program's absence. Copyright The Gerontological Society of America. Bushy A. Rural nursing research priorities. J Nurs Adm 1992 Jan;22(1):50-6. The magnitude and variety of clinical concerns in rural healthcare delivery mandate a focused plan for building a substantiated body of knowledge. The author identifies research priority areas to develop a body of knowledge for rural nursing. Copyright J.B. Lippincott Co. Bushy A. Rural U.S. women: traditions and transitions affecting health care. Health Care Women Int 1990;11(4):503-13. Warren (1972) proposed a means for determining differences between rural and urban social contexts that expands on the population definitions. Essentially, these differences are geographical, social, and economic in nature, and the health status of individuals in either setting may be affected by these variations. The health issues of women that evolve from these rural factors are the focus of this article. Copyright Taylor & Francis, Inc., Washington, D.C. Reprinted with permission. Bushy A. Rural women. Lifestyle and health status. Nurs Clin North Am 1993 Mar;28(1):187-97. This article presented a "snapshot" of the concerns and issues confronting America's rural women. The discussion highlighted demographic, economic, and sociocultural factors that impact the health status of women living in diverse rural environments. Recommendations were proposed to assist nurses to better address the health concerns of these women. Curtiss CP. Trends and issues for cancer care in rural communities. Nurs Clin North Am 1993 Mar;28(1):241-51. Rural oncology nursing practice combines state-of-the-art oncology skills and knowledge with the opportunity to care for neighbors and friends. Challenges include limited access to specialized health care, coordination of services, and maintenance of continuity of care for patients. Rural oncology nurses are faced with limited opportunities for specialty education, limited resources, few local colleagues, and unique care issues. Rural cancer nursing, however, can be creative and exciting. This article provides an overview of relevant rural health issues, challenges in providing oncology care in rural locations, and strategies for promoting oncology nursing practice in rural settings. Dahl S, Gustafson C, McCullagh M. Collaborating to develop a community-based health service for rural homeless persons. J Nurs Adm 1993 Apr;23(4):41-5. In the current healthcare environment, public health nursing administrators are called on to create and manage programs and services while reducing cost and improving access. Public health science provides a framework on which to base program planning and management. Using this approach, the authors describe the establishment of a health services center to meet an identified gap in service to homeless persons in a rural area. Copyright J.B. Lippincott Co. Davis DJ, Droes NS. Community health nursing in rural and frontier counties. Nurs Clin North Am 1993 Mar;28(1):159-69. This article discusses the nature and problems of community health nursing practice in large, sparsely populated rural areas. Data were obtained from more than 30 rural community health nurses practicing in a variety of settings. Salient characteristics and a beginning descriptive theory of rural community health nursing practice are presented. Dubay L. Explaining urban-rural differences in the use of skilled nursing facility benefit. Med Care 1993 Feb;31(2):111-29. Recent closings of rural hospitals, anecdotal evidence of rural elderly persons having difficulty gaining access to health services, and the large and growing number of elderly persons living in rural areas has renewed concern about access to care for the rural elderly. In this study, 1987 Medicare skilled nursing Facility (SNF) bills were used to examine differences in urban and rural use of the SNF benefit. Using multivariate techniques, the analysis found that Medicare enrollees living in rural and large metropolitan areas used the SNF benefit at a rate 20% and 17% higher than enrollees living in small and medium-sized metropolitan areas, respectively. However, in rural areas the swing-bed program plays a major role in assuring access to the SNF benefit. Without the swing-bed program, rural enrollees would use the SNF benefit at a rate comparable to that of enrollees in small and medium-sized metropolitan areas. The importance of the swing-bed program cannot be underscored, because relative to urban enrollees, rural enrollees disproportionately live in nursing home markets that are not amenable to serving Medicare patients. Copyright J.B. Lippincott Co. Fiene JI, Taylor PA. Serving rural families of developmentally disabled children: a case management model. Soc Work 1991 Jul;36(4):323-7. Family-centered, community-based case management is a key feature of new federal legislation mandating educational and preschool services for all developmentally disabled children. Social work skills, including counseling, planning, coordination, and knowledge of family and community dynamics, are germane to this task. The goal of family-centered case management is the empowerment of parents as caretakers and planners for their children. Highly skilled case managers will be particularly needed in rural areas where families must deal with scarce resources and other environmental constraints. The authors describe a program employing master's-level social work case managers who serve rural Appalachian families with developmentally disabled children. Included is a case illustration that delineates both case management activities and the contextual elements important in working in an Appalachian rural community. Copyright 1991, National Association of Social Workers, Inc. Gold MR, Franks P. A community-oriented primary care project in a rural population: reducing cardiovascular risk. J Fam Pract 1990 Jun;30(6):639-44. A controlled community-oriented primary care (COPC) program designed to reduce cardiovascular risk was conducted in two towns in a poor, rural area of New York State that have populations with high levels of cardiovascular mortality. In both towns, house-to-house visits were used to screen for blood pressure, gather information about cardiovascular risk knowledge and behavior, and provide a cardiovascular educational program. Persons with elevated blood pressure were advised to seek follow-up. Additional interventions, carried out in the study town only, included ongoing follow-up for those with elevated blood pressure and their providers, and sliding-fee medical services for those with financial barriers to care. At rescreening 2 years later, residents of the study population had an adjusted systolic blood pressure 3.1 mm Hg lower than those in the control population (95% confidence interval [CI] = 0.9, 5.3). Furthermore, those who were screened at both rounds had an adjusted systolic blood pressure 2.7 mm Hg lower than those who had not previously been screened (95% CI = 0.6, 4.8). Although knowledge of cardiovascular risk factors increased among those who were surveyed in both rounds, there was little demonstrable effect on cardio-vascular risk behaviors. Difficulties were encountered in engaging the participation of all medical providers, and less use was made of the sliding-scale program than expected. While it appears feasible to implement the technical methodology of a COPC model in a rural setting, it is crucial to engage the support of the local and medical community. Copyright 1990, Reprinted by permission of Appleton & Lange, Inc. Jessee PO, Cecil CE. Evaluation of social problem-solving abilities in rural home health visitors and visiting nurses. Matern Child Nurs J 1992 Summer; 20(2):53-64. A number of studies have shown the value of using home health visitors and visiting nurses in intervention outreach programs designed to provide pre- and postnatal care for low-income women. The purpose of this study was to compare the abilities of a selected sample of professionally trained nurses and nonprofessionally trained home health visitors to suggest and prioritize solutions to a medical dilemma. Data were gathered by the use of a Practical Solutions Test and a Ranking Solutions Procedure. The subjects for the study were 77 females residing in rural counties in West Alabama. The four study groups were comprised of: (a) trained home visitors with 0 to 6 months of experience, (b) trained home visitors with more than 6 months of experience, (c) professionally trained nurses, and, (d) a control group of women with no training or experience. Data were analyzed using one-way analysis of variance (ANOVA). The findings suggest that all of the trained groups were able to generate more solutions to a typical client medical dilemma than could the control group: F(3.76) = 11.79p = .0001. Faced with the same medical dilemma, the nursing group was more likely to suggest medical options over socio-emotional solutions than were the home visitors: chi 2(3.76) = 9.41p = .02. The nurses also prioritized the solutions differently by ranking them in a different sequence. Copyright Reprinted with permission, Nursecom, Inc. Joseph AE, Cloutier DS. A framework for modeling the consumption of health services by the rural elderly. Soc Sci Med 1990;30(1):45-52. This paper reports on an ongoing research program which seeks to assess the implications of population aging for housing, services and transportation in rural communities in the Province of Ontario. Specifically, the focus is on the modeling of health and social service consumption by elderly (over 65) persons. Following a review of the literature on service provision to senior citizens in Ontario, a modeling framework conceptualizing the process of service utilization at both the aggregate (user and nonuser characteristics) and individual (decision-making) levels is introduced. Data on use of community support services drawn from a survey of elderly residents in two communities in Grey County, Ontario (Meaford, population 4380 in 1986, and Markdale, population 1226 in 1986) are used to illustrate the general features of the modeling framework. Particular attention is paid to the ability of the modeling framework to yield insights into the origins of notable variations in service use rates between men and women. Overall, the results are taken to be supportive of the usefulness of the modeling framework as a template for guiding empirical analysis of service utilization patterns. At the same time the case study testifies to the complex and dynamic nature of service provision issues in rural communities. The challenge of providing services effectively to an elderly rural population located in scattered villages and small towns will continue to tax the imagination and resources of responsible agencies. Copyright 1990, Reprinted with permission from Elsevier Science, Ltd, Kidlington, UK. Krout JA. Rural area agencies on aging: an overview of activities and policy issues. J Aging Stud 1991 Winter;5(4):409-24. Mail survey data obtained from 422 rural area agencies on aging (AAAs) in 1987 are used to investigate their characteristics & service activities & to explore rural-urban differences in health & social service availability & accessibility. A clear rural disadvantage in resources & services for the elderly is found, with rural AAAs serving much larger, more sparsely populated areas with poorer & older elderly populations, having much smaller budgets & staffs, & supporting fewer services. Implications for practitioners & policymakers are discussed, arguing that there is a need to address factors associated with rural-urban inequity, eg, intrastate funding formulas, rural service models & training needs, & regulations regarding direct service provision. Mainous AG 3d, Bertolino JG, Harrell PL. Physician extenders: who is using them? Fam Med 1992 Mar-Apr;24(3):201-4. BACKGROUND: Nurse practitioners and physician assistants (physician extenders) are playing an increased role in medical care. The purpose of this research was to determine the proportion of adults who have received health care from physician extenders. METHODS: This study used the subject population of the 1990 Kentucky Health Survey, a probability survey of all households in Kentucky. Study personnel contacted subjects using random digit telephone dialing. Subjects were then interviewed to ascertain whether subjects had received health care from physician extenders and whether they were satisfied with that care. RESULTS: Of 687 participating subjects, 25% had received care from physician extenders during the previous two years, primarily for minor problems and routine checkups. More than 90% of these subjects reported satisfaction with the care they received. Users of physician extenders did not differ from nonusers with respect to income, education, insurance status, self-assessment of health status, or rural versus urban location. Men used physician extenders more frequently than women. CONCLUSIONS: A substantial proportion of the population has used physician extenders. Patient satisfaction with physician extenders is high. Use of physician extenders may be an effective strategy for improving delivery of primary care. Copyright Reprinted with permission from STFM. McElmurray CT, Cone DL, Kammerman SK, Fowler SD. The Winnsboro rural primary care education project. University of South Carolina School of Medicine. J S C Med Assoc 1992 Oct;88(10):493-5. Shi L, Samuels ME, Konrad TR, Ricketts TC, Stoskopf CH, Richter DL. The determinants of utilization of nonphysician providers in rural community and migrant health centers. J Rural Health 1993 Winter;9(1):27-39. The use of nonphysician providers, such as nurse practitioners, physician assistants, and certified nurse midwives, in rural areas is critically important due to the continued primary care access problems. This study examines the major factors influencing the use of nonphysician providers in rural community and migrant health centers based on a 1991 national survey of the centers. This study demonstrates that the employment of nonphysician providers in rural community and migrant health centers is significantly influenced by both supply and demand factors. Among supply factors, there is a significant and positive relationship between the number of total staff and the number of nonphysician providers employed. There is a significant but inverse relationship between the number of physicians and the number of nonphysician providers employed, indicating nonphysician providers primarily serve as substitutes for physicians in rural community and migrant health centers. The supply of nonphysician providers, as measured by the number of affiliated training programs, is significantly related to the employment of nonphysician providers. The demand variable, geographic location, and the centers' staffing policies are also significant determinants of the use of nonphysician providers. Thompson ML, Chambers LG. Rural-based critical care nursing. Nurs Clin North Am 1993 Mar;28(1):171-85. A review of rural-based critical care nursing has demonstrated that quality critical care can be delivered within the constraints of rural practice. The barriers most often found affecting rural care have been described. Proven realistic strategies to these barriers have been delineated. A distinct advantage of rural nursing is the increased amount of change and influence a single nurse can have on the community health care system. The rural nurse manager has the opportunity to create a critical care nursing service with high levels of accountability, that can quickly respond to change, and that produces quality patient care. By accomplishing these goals, rural critical care nurses will leave a meaningful legacy of enhanced lives and improved health for their rural communities. Zadinsky JK, Boettcher JH. Preventability of infant mortality in a rural community. Nurs Res 1992 Jul-Aug;41(4):223-7. Preventability of infant mortality in a rural southern county was examined with a Delphi technique using case summaries of infant deaths during a selected four-year period. The first two rounds were aimed at developing a consensus of panelists' opinions about problems leading to the high infant mortality rate in the study area. From these opinions, an Infant Mortality Preventability Decision Tree and a Problem List was developed. Panelists used these in Rounds III and IV to evaluate the case summaries. There were significant differences in the preventability ratings between physicians and nurses, indicating the importance of assessing individuals' philosophies of preventability when working with an interdisciplinary team of health care providers. TRANSITIONAL CARE Berkowitz G, Halfon N, Klee L. Improving access to health care: case management for vulnerable children. Soc Work Health Care 1992;17(1):101-23. Health care providers are being confronted by a change in childhood morbidity from primarily physical problems to complex problems rooted in the social, family, and environmental conditions that accompany persistent urban poverty. The clustering of multiple problems in one family necessitates redefining preventive and treatment strategies. Yet the lack of coordination among federal, state and local service programs often exacerbates the vulnerability of these beleaguered children and families. Therapeutic case management is a powerful service coordination strategy for increasing access and improving the health of vulnerable children. An ongoing evaluation of one case management model at the Center for the Vulnerable Child at Children's Hospital in Oakland, California is described in this article. Process evaluation data show this model to be effective in improving comprehensiveness and continuity of care among participating families. Copyright By The Haworth Press, Inc. All rights reserved. Reprinted with permission. Brooten D, Brown LP, Munro BH, York R, Cohen SM, Roncoli M, Hollingsworth A. Early discharge and specialist transitional care. Image J Nurs Sch 1988 Summer;20(2):64-8. A model has been designed to discharge patients early from the hospital by substituting a portion of hospital care with a comprehensive program of transitional home follow-up by nurse specialists. The model, initially tested with very low birth weight infants, provides a framework for examining both the quality of care as reflected in patient outcomes and cost of care to specific patient groups. Its design documents nursing interventions and allows for comparisons of care by nurse specialists and other health care providers. Brooten D, Gennaro S, Knapp H, Jovene N, Brown L, York R. Functions of the CNS in early discharge and home followup of very low birthweight infants. Clin Nurse Spec 1991 Winter;5(4):196-201. Various studies have been conducted which explore the different functions of the clinical nurse specialist (CNS). This study details the functions of CNSs providing direct patient care before and following hospital discharge of very low birthweight infants and effect on patient outcome. The study reports on CNS interactions with 36 families whose infants were discharged early from the hospital, and who received discharge planning, teaching, and home followup for 18 months. Brooten D, Kumar S, Brown LP, Butts P, Finkler SA, Bakewell-Sachs S, Gibbons A, Delivoria-Papadopoulos M. A randomized clinical trial of early hospital discharge and home follow-up of very-low-birth-weight infants. N Engl J Med 1986 Oct 9;315(15):934-9. To determine the safety, efficacy, and cost savings of early hospital discharge of very-low-birth-weight infants (less than or equal to 1500 g), we randomly assigned infants to one of two groups. Infants in the control group (n = 40) were discharged according to routine nursery criteria, which included a weight of about 2200 g. Those in the early-discharge group (n = 39) were discharged before they reached this weight if they met a standard set of conditions. For families of infants in the early-discharge group, instruction, counseling, home visits, and daily on-call availability of a hospital-based nurse specialist for 18 months were provided. Infants in the early-discharge group were discharged a mean of 11 days earlier, weighed 200 g less, and were two weeks younger at discharge than control infants. The mean hospital charge for the early-discharge group was 27 percent less than that for the control group ($47,520 vs. $64,940P less than 0.01), and the mean physician's charge was 22 percent less ($5,933 vs. $7,649P less than 0.01). The mean cost of the home follow-up care in the early-discharge group was $576, yielding a net saving of $18,560 for each infant. The two groups did not differ in the numbers of rehospitalizations and acute care visits, or in measures of physical and mental growth. We conclude that early discharge of very-low-birth-weight infants, with follow-up care in the home by a nurse specialist, is safe and cost effective. Brown LP, Gennaro S, York R, Swinkles K, Brooten D. VLBW infants: association between visiting and telephoning and maternal and infant outcome measures. J Perinat Neonatal Nurs 1991 Mar;4(4):39-46. Cohen SM, Arnold L, Brown L, Brooten D. Taxonomic classification of transitional follow-up care nursing interventions with low birthweight infants. Clin Nurse Spec 1991 Spring;5(1):31-6. As new models of nursing care have merged, the need to understand the scope and content of nursing practice has increased. The domain of transitional follow-up nursing, an innovative model, was described by classification of nursing interventions according to the Taxonomy of Ambulatory Care Nursing. Content analysis of records of interventions employed by nurse specialists in the transitional follow-up care of very low birthweight infants yielded results that confirm the appropriateness of the Taxonomy of Ambulatory Care Nursing as a descriptor of transitional follow-up care. Engelke MK, Engelke SC. Predictors of the home environment of high-risk infants. J Community Health Nurs 1992;9(3):171-81. The quality of the home environment is an important predictor of the cognitive and social development of high-risk infants. Community health nurses (CHNs) have played a central role in the assessment and care of families with high-risk infants. We examined predictors of the home environment in a sample of 106 infants discharged from a neonatal intensive care unit. The most consistent predictor of an optimal home environment was an internal parental locus of control. Socioeconomic status affected dimensions of parenting related to cognitive stimulation but not emotional responsivity. Young mothers and those with other children are less responsive to their infants. Males are treated in a more responsive manner than females. These findings suggest that CHNs need to adopt an empowerment model of intervention and focus on the particular needs of young mothers and those with other children. Copyright Lawrence Erlbaum Associates, Inc. Hunter DE, Buick WP, Wellington T, Dzerovych G. Initial evaluation of reorganized hospitalization services in a community mental health center. Hosp Community Psychiatry 1993 Mar;44(3):271-5. OBJECTIVE: Two locked inpatient units at an inner-city community mental health center were reorganized as a hospitalization service consisting of a 22-bed intensive care inpatient unit, an acute-treatment day hospital for 20 patients, and a 23-bed transitional residence program. Levels of functioning of hospitalized patients treated before and after the reorganization were compared to determine if the reorganized program as a whole was more effective clinically than the two inpatient units had been. METHODS: The authors retrospectively compared levels of functioning at discharge of random samples of 10 percent of patients treated in the ten months before the reorganization (N = 66) and 10 percent of the intensive care and day hospital patients treated in the same ten calendar months afterward (N = 78). They also compared data on episodes of seclusion and restraint and on patient flow in the two time periods. RESULTS: The mean functional level of intensive care and day hospital patients treated in the reorganized service was significantly higher than the level of inpatients treated before. The mean duration of episodes of seclusion, but not of restraint, decreased significantly. Total service admissions and readmissions increased from 493 to 603. CONCLUSIONS: The reorganized service encouraged patients to function at higher levels. However, such a program must be affiliated with a diversified and well-functioning outpatient service that can divert some potential inpatients to appropriate alternative treatments and help move patients out of the day hospital-residential program when they are stabilized. Kersten D, Hackenitz E. How to bridge the gap between hospital and home? J Adv Nurs 1991 Jan;16(1):4-14. Many countries have separate organizations for delivering nursing care to patients in the hospital and to patients at home in the community. This separation creates extra difficulties in organizing continuous care for patients discharged from hospital who need nursing aftercare (in The Netherlands, at a rough estimate, 10% of all hospital patients). Special arrangements have to be made to prevent these patients missing out completely. By means of a questionnaire sent to all Dutch regional community nursing organizations, this study makes an inventory of the organizational measures that have been taken in this field in The Netherlands and analyses a model of the effects these measures (and also the effects on contextual factors) have on the number of problems reported by the community in respect of continuity of care. In The Netherlands, the initiative in arranging continuity of care is taken by the regional community nursing organizations or by their operational teams. In most cases, they have been able to make arrangements with the hospitals about the selection of aftercare patients and the transfer of information by transfer forms. Sometimes special continuity nurses are appointed by the community, among other things to organize regular consultation with the hospitals. An eight-item Likert scale was developed to measure the extent of continuity problems. Analysis of the effect of several factors in the model by a stepwise multiple regression analysis, revealed that the consistent use of transfer forms by hospitals was an important tool in reducing the problems. Furthermore, regional community nursing organizations themselves had fewer problems compared with the operational teams to whom arranging continuity is sometimes delegated. Increased personnel capacity within the community is also beneficial. The effect of these last two factors (organizational level and personnel capacity) is, however, overruled, by the negative effect of the size of the regional community nursing organization: the more inhabitants, the more problems there are. Copyright Reprinted by permission of Blackwell Scientific Publications, Inc. Magilvy JK, Lakomy JM. Transitions of older adults to home care. Home Health Care Serv Q 1991;12(4):59-70. To discover the process of admission and transition of older adults to home care following hospital discharge, or during periods of illness, ethnographic methodology was used to explore the experience of 65 participants in the "culture" of home care: patients, families, nurses, home care staff, and discharge planners. Two themes resulting from ethnographic analysis are presented: identification of patients and needs and transfer of information. Support from family and friends was an essential addition to referral by discharge planners, physicians, and casefinding in facilitating transition to home care. Accurate, timely patient information was found to expedite home nursing assessment and insure continuity of care. Copyright By the Haworth Press, Inc. All rights reserved. Reprinted by permission. Malcolm L. Service Management: A New Zealand model for shifting the balance from hospital to community care. Int J Health Plan Manag 1991 Jan-Mar;6(1): 23-35. Perceiving a need for a better balance between hospital & community-based health services, a model has evolved in New Zealand in which service planning & coordination are overseen by area health boards, each of which is responsible for administering all public, private, & voluntary health services for its designated population. Service management is described in detail, & several alternative models of the service concept are presented to show the placement of sectors of primary & secondary health care, & sets of secondary services, hospitals, & community care systems. Factors influencing implementation of service management are discussed, along with the future potential of the service management model. Copyright 1991. Reprinted by permission of John Wiley & Sons, Ltd. Monahan C, Manago R. Technology in pediatric home care: issues in monitoring for quality. J Home Health Care Pract 1992 Nov;5(1):1-11. This article provides information for consumers regarding standards for the use of technology in the home health care pediatric program. The authors describe studies and the experience of one state agency. They provide questions and arguments that can be utilized by hospital discharge planners, case managers, home health care service providers, and families. Naylor MD. Comprehensive discharge planning for hospitalized elderly: a pilot study. Nurs Res 1990 May-Jun;39(3):156-61. The purpose of this randomized clinical trial was to examine the effects of a comprehensive discharge planning protocol implemented by a gerontological nurse specialist as compared to the hospital's general discharge planning procedure. There were no statistically significant differences between groups in length of initial patient hospitalization or in rates of posthospital infections. A statistically significant difference was found when groups were compared on the number of subjects rehospitalized during the study period. The findings of this pilot study reinforce the need for continued study of the impact of comprehensive discharge planning for hospitalized elderly. Naylor MD. Comprehensive discharge planning for the elderly. Res Nurs Health 1990 Oct;13(5):327-47. Discharge planning for the elderly can potentially reduce patient length of hospital stay, prevent rehospitalization, enhance patient outcomes and lessen the burden of care on the families. While increased numbers of elderly are being discharged earlier, there are few data on the process and effects of discharge planning protocols developed specifically for this population. The proposed study will attempt to answer the following questions regarding hospitalized elderly with selected DRG classifications: Are there significant differences between elderly patients who receive the hospital's general discharge planning procedure used for all categories of patients and elderly who receive the hospital's general discharge planning procedure plus a comprehensive discharge planning protocol specific to the elderly and implemented by a gerontological nurse specialist in: (1) Patient Outcomes (length of initial hospitalization; post-discharge morbidity; post-discharge health services; functional status; mental status; satisfaction with care; self-esteem; patient's perception of health status; and stress level); (2) Family Related Outcomes (primary care giver's functional status; mental status; care giving demands; stress level and family functioning); (3) Cost of Care Outcomes (charges for initial hospitalization, rehospitalizations, post-discharge health services; family related costs; and gerontological nurse specialist costs). The study design is a randomized clinical trial with a total of 280 elderly (2 groups of 140). The control group will receive routine discharge planning; the treatment group will receive routine discharge planning plus an elder-specific comprehensive discharge planning protocol. Data analysis will include frequency distributions and summary statistics. For each of the research questions, multivariate analysis of variance or chi-square statistics will be used. Neary S, Kitchen EC. Discharge planning for the elderly: implementation of a continuing care role. Nurs Adm Q 1990 Winter;14(2):16-21. Shegda LM, McCorkle R. Continuing care in the community. J Pain Symptom Manag 1990 Oct;5(5):279-86. Early discharge from the hospital or home health agency necessitates effective continuity of care planning in order to assure that patients and families will have their health care needs met after discontinuance of formal health care services. In this article, we have defined continuity of care from several perspectives, presented two theoretical viewpoints on this concept, and, with four models of care that have actually been implemented, analyzed the commonalities and differences among models. In addition, recommendations for future research and care delivery for the purpose of enhancement of continuity of care have been made. Copyright 1990, by Elsevier Science Publishing Co. Inc. Reprinted by permission. Thurber F, Berry B, Cameron ME. The role of school nursing in the United States. J Pediatr Health Care 1991 May-Jun;5(3):135-40. Changes in the health care needs of American children over the past two centuries have engendered school health programs. Issues related to the role and responsibilities of school nurses within these programs have existed from the beginning. Current societal pressure for schools to assume even greater responsibility for providing health care has necessitated a precise definition of these roles and responsibilities. The purpose of this article is to review existing literature related to school nursing in this country and to describe the results of a study documenting state mandates for health education programs and the role of nurses within these programs. Copyright Reprinted with permission from Mosby-Year Book, Inc. Thurber F, DiGiamarino L. Development of a model of transitional care for the HIV-positive child and family. Clin Nurse Spec 1992 Fall;6(3):142-6. The provision of high-quality, cost-effective care to Human Immunodeficiency Virus (HIV)-infected adults and children is a national priority. During 1991 the number of infected children is expected to increase to over 3,000, with at least 2,000 additional cases manifesting some symptoms of HIV infection. Serious questions exist about the ability of these children's families to acquire the health care services that both they and their children require. This paper will present preliminary findings of a study that describes the physical, behavioral, and developmental responses of children who have a diagnosis of perinatally acquired HIV, as well as the caretaking concerns of the custodial family. Building on this work, a model of transitional home care for these children and their families using pediatric clinical nurse specialist (PCNS) follow-up care will be described. Worley NK, Lowery BJ. Linkages between community mental health centers and public mental hospitals. Nurs Res 1991 Sep-Oct;40(5):298-302. Directors of community mental health centers and superintendents of public mental health hospitals in one state were surveyed to gather data on interagency linkages. Implementation of affiliation agreements, exchange of staff training, and exchange of patient information were investigated. Affiliation agreements tended to be implemented with little difficulty and there was more interagency cooperation than that reported in earlier research. However, exchange of training and staff were still areas of minimal interaction. Geographic proximity was found to have a positive influence and competition a negative influence on cooperation. Further attempts at interagency linkages in the interest of continuity of patient care are recommended. URBAN HEALTH Gelberg L, Linn LS, Usatine RP, Smith MH. Health, homelessness, and poverty. A study of clinic users. Arch Intern Med 1990 Nov;150(11):2325-30. When seeking medical care, homeless persons often turn to health centers that were designed to treat the poor who have homes. To provide for effective medical care, personnel in such facilities need to know how the health care needs of the homeless are different from those of other clinic users. To compare the physical health of these two groups, we conducted a health survey and screening physical examination of 464 patients who attended the general adult and homeless clinic sessions of one of the main neighborhood health centers in Los Angeles County, California. As compared with the poor who have homes, homeless persons were more likely to have dermatological problems (32% vs 21%), functional limitations (median, 2 vs 0 per person), seizures (14% vs 6%), chronic obstructive pulmonary disease (21% vs 12%), social isolation, serious vision problems (22% vs 12%), foot pain, and grossly decayed teeth (median, 1 vs 0 per person). We conclude that to care more optimally for homeless adults, health centers must pay attention to their functional disabilities, substance abuse, skin abnormalities, vision impairment, dental problems, and foot problems. Copyright 1990, American Medical Association. Hurwitz B, Goodman C, Yudkin J. Prompting the clinical care of non-insulin dependent (type II) diabetic patients in an inner city area: one model of community care. BMJ 1993 Mar 6;306(6878):624-30. OBJECTIVE--To evaluate the effectiveness and acceptability of centrally organized prompting for coordinating community care of non-insulin dependent diabetic patients. DESIGN--Randomized single centre trial. Patients allocated to prompted care in the community or to continued attendance at hospital diabetic clinic (controls). Median follow up two years. SETTING--Two hospital outpatient clinics, 38 general practices, and 11 optometrists in the catchment area of a district general hospital in Islington. PATIENTS--181 patients attending hospital outpatient clinics. NULL HYPOTHESIS--There is no difference in process of medical care measures and medical outcome between prompted community care and hospital clinic care. RESULTS--14 hospital patients failed to receive a single review in the clinic as compared with three patients in the prompted group (chi 2 = 6.1, df = 1p = 0.013). Follow up for retinal screening was better in prompted patients than in controls; two prompted patients defaulted as against 12 controls (chi 2 = 6.9, df = 1p = 0.008). Three measures per patient yearly were more frequent in prompted patients: tests for albuminuria (median 3.0 v 2.3p = 0.03), plasma glucose estimations (3.1 v 2.5p = 0.003), and glycated haemoglobin estimations (2.4 v 0.9p < 0.001). Continuity of care was better in the prompted group (3.2 v 2.2 reviews by each doctor seen; p < 0.001). The study ended with no significant differences between the groups in last recorded random plasma glucose concentration, glycated haemoglobin value, numbers admitted to hospital for a diabetes related reason, and number of deaths. Questionnaires revealed a high level of patient, general practitioner, and optometrist satisfaction. CONCLUSIONS--Six monthly prompting of non-insulin treated diabetic patients for care by inner city general practitioners and by optometrists is effective and acceptable. Jamieson M, Campbell J, Clarke S. The block nurse program. Gerontologist 1989 Feb;29(1):124-7. In the Block Nurse Program, existing resources and agencies are used to help keep elderly persons in their own homes with case-management by public health nurses living in the community. In an external evaluation of the program it was documented that a neighborhood long-term care delivery model not only works, but keeps elderly persons in their homes at low cost and with high care standards. Copyright The Gerontological Society of America. Jimenez MA, Jimenez DR. Latinos and HIV disease: issues, practice and policy implications. Soc Work Health Care 1992;17(2):41-51. This paper examines critical issues faced by Latino PWAs and offers suggestions for meeting the needs for community support and care of Latino PWAs and their families. As HIV disease is shifting increasingly to minority communities, social workers need to consider new approaches to developing community care. Drawing on the strengths and informal support networks of the Latino community, the authors suggest ways in which these strengths can form the basis of service strategies that will effectively meet the needs of Latino PWAs. Copyright By the Haworth Press, Inc. All rights reserved. Reprinted with permission. Kelley MA, Perloff JD, Morris NM, Liu W. Primary care arrangements and access to care among African-American women in three Chicago communities. Women Health 1992;18(4):91-106. African-American women of child-bearing age residing in three high-risk communities in Chicago were surveyed regarding their primary care arrangements and access to care (n = 552). This study examined factors which differentiated women who used office-based practices from those who used institutional settings (community clinics, health department clinics, hospital-based clinics) for primary care. Results of multivariate analysis indicate that women who used office-based practices were more likely than those who used institutional settings to see the same provider, to walk to their provider, to have less travel time and to walk in without an appointment. They were less likely to be hospitalized in the past year and less likely to report the availability of family planning at their usual source of care. Satisfaction with care, insurance status and sociodemographic characteristics were not associated with use of a particular facility type. Implications for organizing comprehensive health services for this population are discussed. Copyright By the Haworth Press, Inc. All rights reserved. Reprinted with permission. McElmurry BJ, Swider SM, Bless C, Murphy D, Montgomery A, Norr K, Irvin Y, Gantes M, Fisher M. Community health advocacy: primary health care nurse-advocate teams in urban communities. NLN Publ 1990 Sep;(41-2281): 117-31. In summary, our health advocacy program uses PHC teams in urban, underserved communities to deal with the interaction of social and health factors in solving problems related to access to appropriate (as perceived by residents) and affordable health care. This approach encourages grass-roots participation in problem identification and solution, a fundamental ingredient of community empowerment. Further, this program facilitates community identification of nurses as resource persons who encourage collaboration to improve the community's health status and as health providers who enhance the authority and autonomy of community participation in the resolution of health issues. Weisbrod RR, Bracht NF, Pirie PL, Veblen-Mortenson S. Current status of health promotion activities in four midwest cities. Public Health Rep 1991 May-Jun;106(3):310-7. Community-wide surveys were conducted in Winona and St. Cloud, MN, Eau Claire, WI, and Sioux Falls, SD, in 1986 and 1987 to determine the current status of the supply and demand of health promotion activities in nine categories. Supply and demand indicators were conceptualized and defined as program options (different activities in a coded list) and participation (registrations). An annual inventory of all health promotion activities in each community was complied from interviews with providers of such activities. Interviews of probable community providers was followed by a nomination process to identify others. Providers at worksites were interviewed in a separate study with matching data endpoints. Results show that exercise programs have the highest levels of options and participation in all four cities. On the supply side of total programs offered, there was similarity in rates among three of the cities, with only Winona offering more health promotion opportunities. There was similarity also in the areas of health where most programs are offered, favoring exercise, followed by the heart disease risk factor areas of screening, smoking cessation, and nutrition education. On the demand side of participation, there was similarity in total participation rates among three of the four cities with Sioux Falls showing substantially higher demand. Exercise showed the highest participation in all cities, but there was little similarity among the cities in ranking participation in the other areas of health promotion. In the four cities combined, high levels of program options with low participation were characteristic of smoking cessation. Wenger AFZ. Transcultural nursing and health care issues in urban and rural contexts. J Transcult Nurs 1992 Winter;4(2):4-10. The distinction between urban and rural health care has been based largely on population density, with little attention given to contextual meaning of patterns related to the lifeways of the people. When considering sociocultural factors, the differentiation becomes more complex. In this paper some of the transcultural nursing issues and challenges are discussed in relation to cultural context and health care trends in urban and rural settings. Four urban-rural health-related issues with transcultural dimensions are examined. Migration patterns, diversity among rural communities, utilization of services, and change related to intervention strategies are identified as transcultural nursing knowledge and practice in relation to urban and rural contexts. VULNERABLE POPULATIONS Bernal H, Froman R. Influences on the cultural self-efficacy of community health nurses. J Transcult Nurs 1993 Winter;4(2):24-31. This paper presents the results of factor and regression analyses conducted on the Cultural Self-Efficacy Scale to determine the underlying conceptual structure, and relationship to demographic variables. The Cultural Self-Efficacy Scale was first used with a sample of 190 community health nurses in Connecticut. It has an estimated total scale internal consistency of .97. In 1988, data were collected to examine cross-cultural self-efficacy of nurses working in a variety of settings, including health departments. The principal factor analysis revealed a four factor structure that is conceptually meaningful. Taken together, the four factors accounted for 90% of the total scale variance. Regression analyses showed significant relationships between perceptions of efficacy and demographic variables of race, education, and experience. Berne AS, Dato C, Mason DJ, Rafferty M. A nursing model for addressing the health needs of homeless families. Image J Nurs Sch 1990 Spring;22(1):8-13. Homelessness in the United States continues to be a major social problem directly affecting an estimated three million persons, of whom nearly 30 percent belong to families without permanent shelter. This paper reviews recent research concerning homeless families and the conditions in which they live and outlines the significant health and mental health problems that these families experience. Effective nursing interventions for homeless families using Peszneckers' Model of Poverty are proposed. Nurses must advocate for changes in the social and political conditions that bring about homelessness since the resources to meet the needs of these families are either nonexistent or woefully inadequate. Gottesman MM. Nurse-run clinics providing state- of-the-art homeless care. Second clinic focuses on children and families [interview]. Calif Nurse 1991 Apr;87(4):9. Green RH. Politics, power and poverty: health for all in 2000 in the Third World? Soc Sci Med 1991;32(7):745-55. Health for All by 2000 could become a reality in the Third World countries. On present resource allocation, medical professional and political patterns and trends that is unlikely to happen in more than a few countries. For it to happen requires basic priority shifts to universal access primary health care (including preventative). The main obstacles to such a shift are not absolute resource constraints but medical professional conservatism together with its interaction with elite interests and with political priorities based partly on perceived demand and partly on (largely medical) professional advice. These obstacles are surmountable-as illustrated by divergent performances among countries--but only if education, promotion, efficiency in terms of lives saved and healthy years gained, community participation and political activism for Health for All are more carefully analytically based and pursued more seriously and widely than they have been to date. Copyright 1991, with permission from Elsevier Science Ltd. Kidlington, UK. Helvie CO, Alexy BB. Using after-shelter case management to improve outcomes for families with children. Public Health Rep 1992 Sep-Oct;107(5):585-8. Homelessness and living in shelters have complex and multiple adverse effects on children that lend urgency to assisting families with children to leave shelters and to achieve independent and stable living arrangements. Some shelters offer only short-term housing with no additional support services. Others offer long stays with a comprehensive range of social and economic support services. While living in a shelter, families are faced with such major challenges as finding employment that is adequate to meeting the family's financial needs and locating permanent housing. Because shelter or street living may exacerbate children's health and developmental problems, families with children should move from them into a stable home situation as quickly as possible. The researchers examined some of the specific effects of living in a shelter for homeless families with children in Virginia Beach, VA. They focused on whether the policy of offering families after-shelter case management services for 1 year decreased their average length of the time in the shelter, and whether case management of families with children for 1 year after leaving a shelter increased the proportion of families who obtained permanent housing. A nonexperimental descriptive design was used. In case management after the shelter stay, an advisor worked intensively with families, helping to locate resources and serving as a resource link, assisting with application processes, providing transportation when necessary, and acting as advocate and support person. Some families needed minimal assistance, while others needed more intensive assistance. Kemper P. The use of formal and informal home care by the disabled elderly. Health Serv Res 1992 Oct;27(4):421-51. Using data from the Channeling experiment, this article analyzes the factors associated with the amount of formal and informal home care received by the disabled elderly. The amounts of formal and informal home care used increase with disability, as well as with other measures of need for care. The use of formal care increases, and the use of informal care decreases, with income. The availability of immediate family increases reliance on informal care and reduces reliance on formal care. The findings have implications for the design of proposed programs to expand publicly financed home care for the disabled elderly. Copyright Reprinted with permission from The Hospital Research and Educational Trust. Malloy C, Christ MA, Hohloch FJ. The homeless: social isolates. J Community Health Nurs 1990;7(1):25-36. Within the last 10 years, homelessness has emerged as one of the leading social problems in the United States. This article contains the findings of a descriptive study of the characteristics and health status of a homeless population in a southeastern city. The homeless population is of interest to nurses because it is representative of a specific disadvantaged group, seriously at risk for a myriad of physical and mental problems. The theoretical model, Social Disaffiliation, can serve as a basis for intervention with a variety of underserved or unserved population groups and the data presented provide opportunities for designing nursing intervention strategies. The study was conceived as a way to gather empirical evidence about the specific health-care needs of the community's homeless, to generate a data base on which to estimate that need, and to use the findings to support the establishment of an innovative practice model, a nurse-managed clinic. The literature suggests that on-site clinics, located in emergency shelters, are effective approaches to providing acceptable and accessible health care to the homeless. Nurses are well prepared to be a key part of the solution to one of the most serious problems facing health care in the U.S. today. Copyright Lawrence Erlbaum Associates, Inc. The Public Health Service Action Plan to improve access to immunization services. Public Health Rep 1992 May-Jun;107(3):243-51. The Public Health Service's Interagency Committee to Improve Access to Immunization Services (ICI) has responsibility for improving the immunization protection of the nation's children and other vulnerable populations. ICI's Action Plan to Improve Access to Immunization Services sets 14 goals with 120 action steps for improving immunization services nationwide by (a) increasing coordination among Federal health, income, housing, education, and nutrition programs(b) reducing policy and management barriers that limit access to delivery systems, and (c) strengthening the delivery infrastructure. To accomplish the goals of the plan, there is a $72.0 million increase in funding appropriated in fiscal year 1992 specifically for this purpose. The President's Budget for fiscal year 1993 includes a $24.5 million increase for continued program implementation. The additional resources will be used to address delivery and access problems, which have been determined to be the primary factors limiting immunization for many children. Scupholme A, DeJoseph J, Strobino DM, Paine LL. Nurse midwifery care to vulnerable populations. Phase 1: demographic characteristics of the national CNM sample. J Nurse Midwife 1992 Sep-Oct;37(5):341-8. The purpose of this article is to describe the extent to which certified nurse-midwives (CNMs) provide care to vulnerable populations in the United States and the source of reimbursement for this care. The data were obtained from the first phase of a national study to address the characteristics of women served and cost of care provided by CNMs. Results were analyzed nationally and by American College of Nurse-Midwives regions. Certified nurse-midwives in all types of practices are providing care to women from populations that are vulnerable to poorer than average outcomes of childbirth because of age, socioeconomic status, refugee status, and ethnicity. Ninety-nine percent of CNMs report serving at least one group of vulnerable women, and CNMs in the inner city and rural practices serve several groups. The vast majority of CNMs are salaried; only 11% receive their primary income from fee-for-service. Fifty percent of the payment for CNM services is from Medicaid and government-subsidized sources whereas less than 20% comes from private insurance. Source of income varies by type of setting in which the CNM attends births. The results suggest that CNMs, as a group, make a major contribution to the care of vulnerable populations. Copyright 1992, by Elsevier Science Publishing Co. Inc. Reprinted by permission. Sundwall DN, Tavani C. The role of public health in providing primary care for the medically underserved. Public Health Rep 1991 Jan-Feb;106(1):2-5. Strategies designed to meet the health care needs of Americans should include the issues of access as well as financing. And primary care and clinical preventive services should receive as much national attention as acute care and long-term care. The public health system at the Federal, State, and local levels with its mandate to assure conditions in which people can be healthy must also be incorporated into the national debate. Publicly funded infrastructures for delivering primary health care have become a significant element of assuring access at the community level. This paper examines the expanding role of public health in assuring access to the delivery of primary health care and clinical preventive services to vulnerable populations within the larger issue of who should have access to care and how it should be made available. Special attention is paid to the part played by the Health Resources and Services Administration (HRSA) of the Public Health Service, which, in the Federal fiscal year that began on October 1, 1989, administered some $1.8 billion worth of programs for health care of targeted populations and for the support of training in the health professions. Wallace SP, Lew-Ting CY. Getting by at home. Community-based long-term care of Latino elders. West J Med 1992 Sep;157(3):337-44. Although evidence suggests that the morbidity and mortality of Latino elders (of any Hispanic ancestry) are similar to those of non-Latino whites, Latinos have higher rates of disability. Little is known about influences on the use of in-home health services designed to assist disabled Latino elders. We examine the effects of various cultural and structural factors on the use of visiting nurse, home health aide, and homemaker services. Data are from the Commonwealth Fund Commission's 1988 national survey of 2,299 Latinos aged 65 and older. Mexican-American elders are less likely than the average Latino to use in-home health services despite similar levels of need. Structural factors including insurance status are important reasons, but acculturation is not pertinent. Physicians should not assume that Latino families are taking care of their disabled elders simply because of a cultural preference. They should provide information and advice on the use of in-home health services when an older Latino patient is physically disabled. Copyright Reprinted by permission of the Western Journal of Medicine.
Last updated: 31 December 1996