Liz is an RN-BSN student who works in acute care, and Jay is a BSN student who has just completed an acute care clinical on an orthopedic unit.
Liz says, “I’m glad we are partners for our community health clinical. I am not sure what this experience will be like. I think I will always work in the hospital, so I am not sure what I will get out of it.”
Jay responds, “I know. I have enjoyed clinicals in hospitals and nursing homes. The community is so strange. I don’t totally understand our population health assignments. They seem so different from what I think a nurse does. I am glad I have a partner to work with. Your experience might help us a lot!”
LIZ'S NOTEBOOK Competency #13 Promotes, Assesses, and Coordinates Population Health at the Individual, Family, Community, and Systems Levels of Practice to Create Healthier Individuals, Families, Populations, and Communities
Identifies emerging health conditions that threaten the health status of individuals and families, communities, populations, and the environment including climate change, disasters, and public health emergencies
Utilizes screening and assessment tools to identify individual and community needs and determine when to intervene and/or refer to community resources
Selects public health nursing interventions to mitigate the impact of the social determinants of health on the health status of individuals, families, populations, and communities
Provides care coordination and case management services to individuals and families across the life span to maintain their health and quality of life
Fosters cross-sector and interprofessional collaboration, coordination, communication, and consultation within and across healthcare systems and communities
Describes the core components of population health services provided by public health nurses to populations of interest and populations at risk
Describes the roles and responsibilities of public health nurses in organizing, managing, and evaluating population health services for populations of interest and populations at risk
Source: Henry Street Consortium, 2022
USEFUL DEFINITIONS Care Coordination: An essential component of integrated care, which is the seamless provision of healthcare services from the perspective of the patient and family across the entire care continuum (Agency for Healthcare Research and Quality, 2018, 2022).
“For PHN practice, this involves coordination of care within and across the continuum, including community agencies and schools, addressing social needs for individuals and families and the SDOH at the community and policy level. In addition, the PHN role can include advocating for access to needed services for an individual or a community to maximize health” (American Nurses Association [ANA], 2021, p. 35).
Case Management: A collaborative process of assessment, planning, facilitation, coordinating care, evaluation, and advocacy for options and services to meet client needs. It uses communication and available resources to promote safety, quality of care, and cost-effective outcomes (MDH, 2019b, p. 104).
Health Equity: “When every person has the opportunity to realize their health potential—the highest level of health possible for that person—without limits imposed by structural ...