Program focuses on proactive interventions

Nurses work at sites to case-manage disease

At ProHealth Care in Waukesha, WI, community outreach is more than the hosting of an educational event from time to time.

A team of 23 nurses is strategically placed at 50 community sites, including churches, schools, low-income housing projects, homeless shelters, food pantries, and health resource centers. Their role encompasses health promotion, disease prevention, early detection, and disease management, says Deborah Ziebarth, RN, MSN, manager, Community Benefit for ProHealth Care, a health care system that consists of two hospitals and several clinics.

"We are a continuum of care for our health care organization," explains Ziebarth.

She says health care is not only providing treatment in clinics and hospitals. A certain percentage of the population needs assistance with accessing the health care system, using it effectively, and knowing when to access it. Also, there is the education component that helps with disease prevention and early detection.

Most of the outreach efforts are funded through the nonprofit health care organization's community benefit dollars, as well as partnerships with churches and other organizations.

For example, nurses that work with churches, as part of Parish Nursing, have 50% of their salary and benefits covered by that congregation and the other half by ProHealth Care. That is also the case with most community outreach nurses as well, although ProHealth pays 100% of the benefits and salaries of the nurses that work in eight elementary schools.

Ziebarth says the Community Benefit program includes unique partnerships. One church helps support a nurse that not only works within the congregation, but also at three homeless shelters as part of the church's mission outreach. Another church helps support a nurse at a food pantry as part of its mission outreach. Two churches have pooled their resources, each providing 25% of the salary and benefits, in order for the nurse to work at a low-income mill site providing health care access to an underserved population.

No matter how a salary is covered, each of the outreach nurses is an employee of ProHealth Care and under Ziebarth's supervision.

Nurses tailor activities to the population they serve. For example, one Parish Nurse initiated a walking program to aid in disease prevention called "Walking to Jerusalem." Participants tracked their steps and mileage along a map on the wall to determine how close they were to reaching their destination.

To promote good health, nurses may hold a class or organize a health fair that pertains to the needs of their target population. Screenings are often held for early detection, including blood pressure screenings or blood glucose screenings.

Nurses also advocate for patients. For example, a patient may have a chronic disease and need a certain type of medication that he or she cannot afford. The nurse may then intercede on behalf of the patient, asking the physician to write a prescription for a less expensive medication.

"The role of the nurse is to decrease barriers of access for the individual and to improve the health of the community we are serving," explains Ziebarth.

Assessing community needs

To help determine the needs of the population a nurse serves, members of a congregation or a community are incorporated into the program. For example, Parish Nurses will work with a health ministry group or leader at the church to gain insight into the needs of the congregation, says Ziebarth. Also, these leaders provide needed assistance at health fairs and other events. A Parish Nurse will survey the congregation as well to determine how to meet the health needs of the population.

At the Hispanic Health Resource Center, where three outreach nurses work, an advisory group meets with the nurse quarterly to give direction. The group is always given information about the outcomes of its advice, so it recognizes its ownership in what takes place for the health of the community, says Ziebarth.

In addition, respected individuals within the community who are bicultural and bilingual are trained to assist in health promotion and disease prevention. They will often do car seat training or organize walking groups, so the nurses can concentrate on specific education and case management.

Ziebarth says ProHealth Care can be very creative in how to meet the health needs of communities. For example, one nurse, whose work is funded in partnership with a church, splits time between a free clinic in downtown Waukesha and a storefront shelter for the homeless in the downtown area. Volunteers from the church assist the nurse at the storefront by doing such tasks as accessing pharmaceutical programs that help the homeless obtain medications.

"Her community is the underserved population of downtown Waukesha, and she spends some time at the free clinic, so there is a referral to and from the clinic. It is a great model," says Ziebarth.

One important element of the program is computerized client documentation that allows nurses in the program to share information. Everyone who comes in contact with the client, which may be at a homeless shelter, public school, or food pantry, knows what care and education he or she has received.

"We have complete continuum of care, for we know what others are doing in caring for this person," says Ziebarth.

In addition, the nurses might flag physicians at a clinic when there is something they should know to improve the patient's care. In this way, each patient has the best outcomes, she adds.

This record keeping helps ProHealth Care track patient outcomes. Also, nurses keep diaries on patients by writing their clients' stories in order to track outcomes, says Ziebarth.

When choosing how best to spend community dollars, Ziebarth says her department looks for an entry point to a particular population and an environment that will support a nurse and take some ownership. To reach its goals, the organization developed a strategy in 2007.

The strategy has a list of target populations that include: non-English-speaking populations; poor children and family units; frail and/or isolated elderly; indigent (uninsured) and working poor (underinsured); homeless; mentally disabled; and victims of violence.

Also identified are key areas of community health need including: access to primary care services and a medical home; dental services; effective chronic disease management and support; mental health services; and prevention and early detection.

The strategies are designed to promote the development of services that do the following:

• Remove barriers to service, e.g., language, financial, lack of knowledge, and navigation skills.

• Encourage prevention and early detection of illness.

• Provide care management and advocacy services.

• Relate to local needs assessment findings and, as appropriate, state or national health plan priorities.

• Emphasize evidence-based programming/models.

• Create partnerships that build on existing ProHealth Care service/strengths and address key areas of need.

• Create partnerships with organizations that have the same target population and complementary goals.

• Create partnerships that promote community capacity building, collaboration, achieve shared vision, and maximize leveraging of resources.

"ProHealth Community Benefit Program is a partnership with other organizations that have a shared vision. It has now been working for 15 years and keeps growing," says Ziebarth.