1. Chapter 22: Community Health Applications By: Mary Michaela Galaura

2. Objectives: 1. Define the scope of community healthy nursing (CHN). 2. Describe the vocabularies and classifications used for community health systems. 3. Discuss data sets and their use in CHN. 4. Discuss computer systems for community health. 5. Discuss use of telemedicine in community health. 6. Discuss future trends.

3. Definition of CHN  A synthesis of nursing practice and public health practice applied to promoting and preserving the health of populations.  Requires a comprehensive understanding and knowledge of the framework of the community, its resources and the sociocultural issues impacting people within a community.

4. Focus: The Population  Standards of CHN incorporate :  health promotion  health maintenance  health education  health management  coordination continuity of care using a holistic approach.  It is practice in public health departments, ambulatory care settings, group practices, outpatient clinics, freestanding community-based clinics, and in homes.

5. Targets:  Usually targeted at a specific function like population focus, continuity of care needs, or billing services for documenting home health care assessment to create a home health related group (HHRG)  Information system structure have other functions like a simple tracking for clinical data or more complex applications related to portable medical data, billing, financial applications and, statistical reporting and decision support

6. CHN System Development  CHN agencies used computers since the late 1960s.  Mostly functioned for regulatory compliance, billing applications, and statistical reporting related to community health.  Grew primarily due to consumer choice, cost control initiatives, and the increase of numbers of healthcare recipients with chronic illness.

7. CHN System Development (cont’d)  The CHN System Development contributes to management information system (MISs)  transforms data into information to measure outcomes, track client progress, exchange healthcare information among physicians, nurses, insurers, managed care companies, regulatory agencies and public reporting, and analyze financial data.  These systems supported clinical care delivery, electronic billing, and had the potential for multiple user access.

8. 4 Domains of MISs for Practice 1. Public Health focused on population interventions and outcomes related to epidemiologic and/or mortality and morbidity trends 2. Home Health focused on skilled nursing care for individuals in the home and the outcomes related to care delivery for individuals or aggregated populations

9. 4 Domains of MISs for Practice (cont’d) 3. Special Population Community Practice (mental health) focused on specific diagnostic care and/or treatment needs and outcomes related to the care provided to those groups 4. Outpatient Care focused on intermittent, episodic, and preventive care for individuals and/or put together groups inclusive of national health prevention standards.

10. Home Health  Medicare and Medicaid Legislation (1965)  Home health  describe the provision of preventive, therapeutic, restorative and supportive healthcare in the home  new legislation increased HHAs (home health agencies)  Systems captured patient demographics,visits, accounts payable, journal entries for the purpose of producing standard reports, billing forms, regulatory documents, visit summaries, and financial balances.

11. Home Health (cont’d)  Balanced Budget Act (BBA of 1997)  With its enactment need for info moved beyond billing info, stats info, and the tracking of clinical data  Center for Medicare and Medicaid Services (CMS) instituted prospective payment system (PPS) forms are based on OASIS (clinical severity, functional status, & service utilization  Integrated form of payment allows for linkages between home healthcare providers, state regulatory bodies, and the fiscal intermediary responsible for paying Medicare reimbursement directly to the agency.

12. Home Health (cont’d)  Outcome Measures  CMS started using OASIS data set in order to monitor outcomes and adverse events based on risk-adjusted patient characteristics for all Medicare-certified HHAs  JCAHO (Joint Commission on accreditation of Health Care Organizations) under outcome- based quality improvement supported it as indicator of quality and improvement.

13. Public Health Definition :  coordinated effort at local, state and federal levels whose mission is fulfilling society’s interest in assuring conditions in which people can be healthy, as defined by the Institute of Medicine (IOM) Focuses on : 1. Preventing, identifying, investigating and eliminating community health problems; 2. Assuring that the community has access to competent personal healthcare services 3. Educating and empowering individuals to adopt more healthy behaviors.

14. Public Health (cont’d) State and Local Health Departments  1970s-1980s state/local official health depts. Developed statistical reporting system for processing info on nursing personnel, programs and services  Florida Client Information (first statewide computerized community health systems)

15. Public Health (cont’d) Public Health Challenges  Issues of bioterrorism,  Health plans recognizing need to evaluate prevention activities to improve quality of live and reduce costs  Healthcare providers recognizing need to integrate public data into individual health records  Health depts. Needing to monitor impact of community-wide interventions for improving the health of populations in communities.

16. Public Health Challenges (cont’d)  Software developers responded with developing electronic IT systems instead of outdated data processing/computer systems.  Allow for: 1. Relational databases that facilitate retrieval of data for multiple purposes without rekeying 2. Manipulation of data to create information and knowledge 3. Point of care devices, computerized patient records (CPRs) and/or EHRs 4. Clinical repositories as a strategic resource for quality and justice 5. Electronic interfacing systems to facilitate the sharing of data.

17. Data Sets Criteria:  Utility for multiples users  Terms that can be defined and measured  Common or shared language that is universally understood  Relevance to national or local needs  Uniformity with other applicable data sets  Data can be structured in compliance with Health Insurance Portability and Accountability Act (HIPAA)  Data can be collected easily and accurately through functions of service delivery.

18. Selected Data Sets  National League of Nursing developed first prototypes for basic minimum data set for CHN even though it is no longer used.  The nursing minimum data set (NMDS) made by Weley and Lang (1988) focused on 12 major elements  Uniform Data Set for Home Care and Hospice  Outcome and Assessment In formation Set (OASIS)  Outcome-Based Quality Improvement  Health Plan Employer Data and Information Set (HEDIS)

19. Vocabulary Languages  Vocabularies are validated clinical reference languages, taxonomies, or terminologies that make healthcare knowledge more usable and accessible.  Intensity Classifications  Clinical Class Classification System (CCC)  Clinical Care Pathway

20. Omaha System  Research-based, comprehensive taxonomy designed to generate meaningful data following usual or routine documentation of client care  Consist of Three Components: 1. Problem classification scheme 2. Intervention scheme 3. Problem rating scale for outcomes

22. Community Health Intensity Rating Scale  Original CHIRS was prototype classification tool that included 15 parameters that that represented the same 4 Home Health System Domains in the Omaha System: environment, psychosocial, physiological, and health behaviors

23. Community Health Systems  Categorical Program Systems  Screening Programs  Registration Systems  Management Information Systems  Statistical Reporting Systems  National Electronic Disease Surveillance System  Special Purpose System  School Health System

24. Home Health Information Systems  Time-sharing Systems  Stand-Alone systems  Portability of Data  Point of Care Systems  Reimbursable Models  Managed Care  Scheduling Systems

25. Telemedicine  Being implemented to replace face-to-face home visits. Refers to electronic transfer of medical info and services (voice, data, and video) from one site to another using telecommunications technology.  Technology includes:  Telemonitors with peripheral biometric attachments  Videophone with two-way audio-video connectivity  In home message devices with disease management education, advice, and vital sign monitoring  Video cameras for monitoring all aspects of care delivery particularly on focusing on wound management and home care aide supervision  PCs with internet connectivity  Video conferencing

26. Community Health Telemedicine Systems  Internet Applications 1. Assist in self-diagnosis and preventive medicine 2. Reduce unnecessary outpatient visits 3. Provide self-directed triage 4. Eliminate the “worried-well” aspects of many patient- provider interactions  Benefits: Improved patient and provider satisfaction Patient time savings in tracking and receiving info Reduced need to see a healthcare provider personally Reduced info calls More cost-effective care  Telemedicine Devices

27. Community Health Network Systems  An innovative ambulatory care system developed to provide services via computer  Performs actions but not diagnoses: Download the patient record from hospital to the home database Enter a series of questions about symptoms Track self-care Provide additional info on the condition if self- care is chosen to assist the client to resolve the problem

28. Home High-Tech Monitoring Systems  Using computers to link patients at home to healthcare facilities  Monitors biophysical parameters  Remote defibrillator  Digitalized x-rays, ECG, electronic stethoscopes, and interactive video equipment  Alert systems

30. Educational Technology Systems  Applications of these systems provide communication linkages, information access, and educational materials  Meets the need for clients to reach beyond their environment to see and hear(experience, view, visualize)  Healthy Town (program of VNAHPO)  Healthy town is a unique program of the VNAHPO. It is a partnership with the Area Agencies on Aging (AAA) who serve seniors at neighborhood nutrition sites.  Website: www.vnahealthytown.org  Baby Care Link is a multifaceted telemedicine communication application of Beth Israel Deaconess Medical Center design to provide individualized information to families of very low birth weight infants.

31. Future Trends  Community health information networks will link multiple providers, patient info, and regulatory bodies on a single system allowing for integration of data, continuity of care, and the tracking of outcomes across service providers.  Decision support systems will become more sophisticated  Geographic information system technology will also be incorporated

32. What Our CIs Think We’re Doing During CHN What We’re Really Doing

33. THE END Thanks For Listening!