Public Health Nursing

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The Indian Health Service (IHS) Division of Nursing, Office of Public Health Nursing (PHN) announces a new competitive grant applications for community based model of PHN case management services. This program is authorized under the Snyder Act, 25 U.S.C. 13; Section 301(a), Public Health Service Act, as amended; and the Indian Health Care Improvement Act (IHCIA) 25 U.S.C. 1652. This program is described at 93.933 in the Catalog of Federal Domestic Assistance (CFDA). The purpose of the program is to improve health outcomes of high risk patients through a community case management model that utilizes the PHN as case manager. Research indicates nursing case management is a cost effective way to maximize health outcomes. The PHN Model of community based case management utilizes roles and functions of PHN services of assessment, planning, coordinating services, communication and monitoring. The goals and outcomes of the PHN Case Management model are early detection, diagnosis, treatment and evaluation that will improve health outcomes in a cost effective manner. This model utilizes all prevention components of primary, secondary and tertiary prevention in the home with patient and family. The community based case management model addresses the scope of practice of PHN working with individuals and families in a population-based practice. Health disparities are greater for American Indian/Alaska Native (AI/AN) communities than the general United States population. Infant mortality is greater in the AI/AN population than United States in general, suicide rates are greater, unintentional injuries are greater, and chronic disease is increasing. This project will focus on a PHN community based case management model. The project will be conducted in a phased approach, using the nursing process - assessment, planning, implementation, and evaluation. First Phase: Assessment - Conduct a comprehensive community assessment. The Senior Nurse Consultant will recommend a community assessment tool and provide appropriate training to the grantees in the Fall of 2008. Include, if available, pertinent data from the various community assessments and local health status data of the community in the community assessment. In addition, obtain input from key stake-holders such as, community members and healthcare administration and community health groups to determine the health care priorities. Develop plans for project sustainability. The PHN case management model will develop case management services addressing the priority health issues identified from the community assessment. The PHN case management program will establish policies and procedures, best practice (BP) for services, and mechanisms for tracking outcomes using the recommended PHN community based case management tool to improve the health care status. Second Phase: Planning - After the community assessment is completed and priorities for Public Health Nursing case management services are determined, planning the case management model project will begin. Obtain additional staff training needed for the community based case management model and additional training needed such as evidence based practice, motivational interviewing, and any other training that would be applicable to the health issues addressed in the case management model. Plan specific case management services such as admission criteria, caseload size, policies and procedures, and an evaluation plan to include data tracking for outcomes generated and feedback to key stakeholders. Develop program guidelines. Obtain approval from healthcare administration. Develop patient education materials and community education materials for the program. Third Phase: Implementation - Case management program includes admission criteria, caseload size, and at risk population to receive this service with appropriate care standards. Patient caseload established. Monitor progress and make adjustments as needed. Track patient data outcomes. Continue to plan ongoing sustainability of program after award period ends. Forth Phase: Patient Satisfaction Surveys - Data evaluation obtained from key stakeholders. Evaluate program services from population served and obtain satisfaction surveys. Evaluate and revise if needed, review policy and procedures and education materials. Report back to key stake-holders progress of the project. Each site will share program material with IHS Headquarters PHN program. This will be shared IHS-wide for replication of the project across IHS with credit given to the organization that developed the material. Poster presentation or oral presentation will be given at the National Combined Councils or IHS annual national nursing meeting. The Senior Nurse Consultant for PHN will make one or two site visits to each site. The program established must be sustainable after completion of the project.

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