The structure and functions of the health care delivery sys- tem, as well as particular legislative acts, have had a significant impact on community health nursing. Community health nurses have had to adapt to a constantly changing system.
They have developed innovative modes of service delivery, such as community-based nursing centers for health educa- tion, counseling, and screening of low-income populations.
They have learned to practice in a variety of settings extend- ing beyond homes, worksites, schools, churches, clinics, and voluntary agencies. They have acquired skills in teamwork, leadership, and political activism. They have recognized the importance of outcomes research to document the value of nursing interventions with at-risk populations.
At the national, state, and local level, community health nursing has important ties to both private and public health agencies. Either type of organization may employ community and public health nurses. When serving in the public sector, they often provide consultation, serve on boards, volunteer their services, or collaborate with private-sector health organ- izations to ensure quality and access of care to the broader community. Examples include joint efforts to promote certain types of health legislation and collaboration to produce and disseminate health education materials targeting specific CHAPTER 6 Structure and Economics of Community Health Services
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populations (Porche, 2004). Sometimes, community health nursing services operate within a single organization that combines public- and private-sector organization and funding.
An example is the Metropolitan Visiting Nurse Association of Minneapolis, Minnesota, which is a combined public–private agency supported by taxes and voluntary funds.
Community health nurses also have many opportunities to serve in international health. Some work with the WHO, PAHO, or other agencies to assist in direct care projects such as famine relief, immunization efforts, or nutritional screen- ing and education programs (see Chapter 16). Other nurses serve as health planners, assist with policy development, conduct collaborative needs assessment projects and research efforts, or engage in program development.
Summary
Many factors and events have influenced the current struc- ture, function, and financing of community health services.
Understanding this background gives the community health nurse a stronger base for planning for the health of the pop- ulation under her care.
Historically, health care has progressed unevenly, marked by numerous influences. Primitive practices of early centuries were replaced with more advanced sanitary meas- ures by the Greeks and Romans. The Middle Ages saw a serious health decline in Europe, with raging epidemics leading to extensive 19th-century reform efforts in England and, later, in the United States.
Organized health care in the United States developed slowly. Public health problems, such as the need for isolation of persons with communicable diseases and control of envi- ronmental pollution, prompted the gradual development of official interventions. For example, quarantines to control the spread of communicable disease were imposed in the late 1700s. Sanitary reform was pursued more vigorously during the 1800s. Local and then state health departments were formed starting in the late 1700s. By the early 1900s, the federal government had assumed a more active role in public health, with a proliferation of health, education, and welfare services.
For years, efforts to address community health needs have been made by public agencies and private individuals.
These two arms of service were not well coordinated in the past. Only gradually and recently have they begun to work together to form an emerging health care system.
The public arm of health services includes all govern- ment, tax-supported health agencies and occurs at four levels:
local, state, national, and international. Each level deals with the health needs of the population encompassed within its boundaries. Each level has a different structure and set of func- tions. Public health services include three core public health functions: assessment, policy development, and assurance.
Private health services are the unofficial arm of the com- munity health system. They include voluntary nonprofit agen- cies as well as privately owned (proprietary) and for-profit agencies. Their financial support comes from voluntary con- tributions, bequests, or fees. Private health organizations often supplement and complement the work of official agencies.
The delivery and financing of community health serv- ices has been significantly affected by various legislative acts.
These acts have prompted such innovations as health insur-
ance and assistance for the poor, the elderly, and the disabled;
money to train health personnel and conduct health research;
standards for health planning and delivery; health protection for workers on the job; and the financing of health services.
Health care economics studies the production, distribu- tion, and consumption of health care goods and services to maximize the use of scarce resources to benefit the most people. This science underlies the financing of the health care system. It is influenced by microeconomics as well as macroeconomics.
Health care is funded through public and private sources, which fall into three categories: third-party payers, direct consumer payment, and private support. Health care services have been reimbursed either retrospectively, typical of FFS plans, or prospectively, typical of most HMOs.
Several trends and issues have influenced community health care financing and delivery and are important in understanding health care economics and helping to improve community health. They include cost control, finan- cial access, managed care, health care rationing, competi- tion and regulation, managed competition, universal cover- age, a single-payer system, and health care reform.
The changing nature of health care financing has adversely affected community health and its practice in three important ways: (1) retrospective payment without limiting costs, tax-deductible employer contributions for health care coverage and nontaxable employee health bene- fits, together with a lack of consumer involvement in cost sharing, have created disincentives for efficient use of resources; (2) because the health care system traditionally has reimbursed only for treatment of the ill or disabled, with no reward for health promotion and prevention efforts, it has promoted incentives to focus only on illness care; and (3) the competition model, which has long driven up health care costs and eliminated many from being able to afford health care services, has generated a conflict with the basic public health values of health promotion and disease prevention for all persons. Health care reforms have been proposed, but the United States remains the only industrialized nation without some type of universal health coverage. We also rank signif- icantly lower than most other developed countries on health indicators, such as infant mortality and life expectancy.
Public health nurses can lead the effort in making health care more accessible to all citizens and encourage policies and practices that promote health, rather than reward illness. ■
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UNIT 2 Public Health Essentials for Community Health Nursing❂ ACTIVITIES TO PROMOTE CRITICAL THINKING
1. Interview someone at your local health department.
How do the services offered compare with those listed in this chapter? How do PHNs in this agency incor- porate the core public health functions?
2. Make an onsite visit to your state health depart- ment or visit its website. Compare its functions with the core public health functions described in this chapter. Identify areas where improvement may be needed.
3. Conduct an interview onsite with someone at a private health agency, voluntary agency, or community-based
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165non-governmental organization (or NGO). Compare the agency’s functions with those listed in this chapter for private health agencies. Describe how this agency works collaboratively with public health agencies and other community organizations. What is the role of the nurse in this agency? How does the role compare to PHNs in the local public health agency?
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Does your campus have a student health center?
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