CHAPTER 84How Community-Based Organizations Are Addressing Nursi.docx

CHAPTER 84
How Community-Based Organizations Are Addressing Nursing's
Role in Transforming Health Care
Mary Ann Christopher, Ann Campbell
“The day may soon dawn when we Americans can enjoy a
measure of life and health that is consistent with our
extraordinary resources and the intelligence of our people. The
pioneers have begun their work; it is far from finished. New
fields, new enterprises, are visible. The times call for the high
spirit of the courageous pioneers among physicians, scientists,
and nurses.”
Lillian Wald
This is a time of rapid transformation in health care, one in
which community health nursing has a critical role in advancing
individual and public health. As the United States integrates the
mandates of the Affordable Care Act (ACA), community health
organizations have a pivotal role in affecting the health status
of the nation, particularly for vulnerable populations. The
Institute for Healthcare Improvement, through the construct of
the Triple Aim, calls on all members of the health care team to
improve the health of the population, improve the consumer
experience and reduce the cost of care. The Institute of
Medicine's (IOM) report on The Future of Nursing has charged
nurses to become equal partners in the development of health
policy and practice (IOM, 2011). The IOM report Public Health
and Primary Care has challenged practitioners to coordinate
efforts for the betterment of patients (IOM, 2012a).
Community-based organizations are strategically positioned to
provide the leadership as well as the integration and
coordination of services necessary to carry out these aims.
Further, the community-based sector of the nursing profession
is poised to influence the transformation of health care delivery
by drawing on principles that are core to the discipline. By
partnering with communities, creating innovative approaches to

care as the system evolves, and engaging the communities they
serve, community health nurses can deliver on the promise of
quality health care for all. This chapter discusses the
approaches of the Visiting Nurse Service of New York
(VNSNY) to mobilize the strengths of the community to
improve public health, establish cross-continuum
interprofessional teams to affect the continuum of the patient
care journey, and promote public policy to advance funding
methodologies that more adequately consider risk factors of
vulnerable populations.
Community as Partner and the Community Anchor
Community Anchor is a concept that is being developed by the
VNSNY as a way to build healthier communities. The
Community Anchor is a term that suggests if nursing is going to
exercise its responsibility for the individual as well as public
health, the profession must recommit to its traditional focus on
grassroots needs assessment and service provision, so brilliantly
illustrated by the work of Lillian Wald, founder of the Henry
Street Settlement House, the VNSNY, public health
nursing, 665occupational health nursing, the first playground in
New York City, and more. To best meet the health needs of
individuals, nursing must work in partnership with the
community. These partnerships act as bridges, connecting
public health nursing both to individuals and to the wider
community.
The Community Anchor works locally to build or support
programs that address social determinants of health, offering
reinforcement to communities as they work on revitalization
efforts. The Community Anchor uses the community needs
assessment to inform program development and create a
foothold in the community's areas of vulnerability and
strengths, and weaves solutions in tandem with the community.
The Community Anchor teams comprise interprofessional
members, who in most cases are members of the communities
they serve. The following questions help the team to develop
key organizing constructs that guide their interventions:

• What are the strengths and assets of the community?
• What are the needs and goals that the community identifies for
itself?
• Who are the key stakeholders?
• What are the goals in care?
• What community initiatives are already underway upon which
we can build?
Once these questions are answered, tools for the development of
Community Anchor initiatives include:
• Mobilizing front-line public health visiting nurses to identify
unmet needs and strategic directions of the community
• Mapping assets, or inventorying the assets and gaps in
community resources and potential, across a broad spectrum of
health, mental health, social service and housing providers, and
faith-based coalitions
• Identifying existing community action groups and fostering
collaboration
• Partnering with hospitals, ambulatory care networks, and other
players to better address the health needs of the community
The Community Anchor strategy, by design, takes different
forms based on unique characteristics of each community. In
Washington Heights, a diverse, at-risk community in upper
Manhattan, the anchor initiative has taken the form of a Health
Village, aimed at impacting the self-care management of
community residents 60 years of age and older diagnosed with
diabetes mellitus. The VNSNY has partnered with supermarkets,
housing providers, primary care providers, and an academic
medical center to create a safety net of support around a low-
income population struggling to follow through with treatment
regimens. This patient-centered community network provides
the access points for the residents to receive care and coaching
in support of their self-management. In fact, residents can
access any of the health or social services providers through
this community network. It becomes the vehicle for their
connection to a comprehensive system of health and social
service providers.

In an area of the Rockaways on Long Island that was hit hard by
Superstorm Sandy, the anchor initiative focuses on developing
specialized registered nurses and licensed clinical social
workers, called community wellness coaches (CWCs), with the
goal of integrating medical and social services to achieve health
promotion and disease prevention and to avert unnecessary
emergency department visits. Funded by a New York State
Social Services Block Grant, the CWCs direct teams of wellness
navigators (WNs), who live in the neighborhoods they serve,
centered around hot spots such as senior housing sites,
pharmacies, churches, and community centers where health
disparities are high and access to services is low. The VNSNY
blends lessons learned from its experience in post-Superstorm
Sandy recovery efforts with evidence-based elements from a
number of coaching models that target at-risk populations,
including the Geisinger ProvenHealth Navigator Model
(Hospitals in Pursuit of Excellence, n.d.), the Kaiser Grace
Model (Bielaszka-DuVernay, 2011), the Care Transitions
Intervention (Coleman et al., 2006), and the Transitional Care
Model (Naylor et al., 2011).
The objective of this Community Anchor initiative is to conduct
outreach to 5000 community residents over a 24-month period
through two programs: 1000 residents will be reached through a
one-on-one intervention model, and 4000 will be 666impacted
through a group-focused public health model. For the 1000
members in the CWC program who receive one-on-one
coaching, community members are paired with the professional
coaches for no less than 3 monthly visits. The community health
nurses and social workers structure their interventions within
the health coaching framework: self-management support,
serving as a bridge between clinician and patients, navigation of
the health care system, emotional support, and continuity
(Bennett et al., 2010). To ensure that the intervention is
culturally competent and relevant, WNs are recruited from the
neighborhoods they serve to extend the intervention of the
professional coaches. The role of the WNs involves fostering

patient engagement, facilitating adherence to the plan of care,
reinforcing health teaching, and assisting with negotiation of
the health care system. The employment of local people
likewise facilitates the economic development of the
neighborhoods. Among those who serve as WNs are VNSNY
home health aides who were promoted to this role and then
immersed in a structured course of health navigation and
coaching. With this enhanced competency, they now have
advanced on the career ladder as well, fulfilling the charge of
the IOM Future of Nursing report that each member of the
interprofessional team function at their highest level of
education and training (IOM, 2011). This commitment to the
direct care workforce further supports the needs of
economically disadvantaged communities.
Building on the assets of the community, the interprofessional
teams promote public health by employing an aggregate
approach to health intervention. Partnering with key community
stakeholders, they design and implement Community Wellness
Campaigns aimed at increasing awareness and linking
community members to resources on weight management, age
appropriate immunizations, health screenings, cardiovascular
health, nutrition, and mental health.
Accountable Care Community
A longer-term initiative that will leverage these partnership
approaches is the accountable care community (ACC). A
concept developed in Akron, Ohio, the ACC focuses on
integration within a specific geographic area to bring about
improved health outcomes. The ACC encompasses the medical
and public health systems, community stakeholders at the
grassroots level, and community organizations whose work
often encompasses the entire spectrum of the determinants of
health (Janosky et al., 2013). Our goal is to obtain federal
demonstration funding to test the model of care in collaboration
with partners in Nassau County. Through this project, the
VNSNY would extend its efforts through geographic morbidity
and mortality mapping to at-risk neighborhoods. In a

partnership with the community, a public hospital, local housing
providers, and social services organizations, visiting nurses
would function as population care coordinators to develop a
population-based intervention model through which all partners,
including community residents, have the opportunity to share in
financial rewards that will result once improved health
outcomes are achieved.
Superstorm Sandy
This work expands on an approach that the VNSNY has been
implementing in a community significantly devastated by
Superstorm Sandy. Project Hope is a strengths-based model in
which the VNSNY recruited members of the community who
had effectively overcome the impact of the disaster to work as
crisis counselors, fostering resiliency among survivors within
the community. A survivor is defined as someone who is
experiencing a “normal reaction to an abnormal situation,” and
the goal is to empower the survivor to draw upon his or her
preexisting coping skills. The crisis counselors work with the
survivor to problem solve, provide resources, and support the
survivor in taking actions to recover, encompassing a range of
behaviors, such as scheduling medical appointments, securing
Federal Emergency Management Agency (FEMA) funding,
negotiating home insurance coverage, and promoting optimal
functioning within the family unit. The survivors regain a sense
of control and accomplishment. Project Hope, funded through a
public/private partnership, has 667resulted in the provision of
over 20,000 community-based visits to those suffering
posttraumatic stress from the impact of the storm. This
strengths-based intervention model addresses the mental health
impact of disaster and reaches out to those who have become
isolated, toppling the disparities that arise when homes have
been lost, communities leveled, and services destroyed.
This work has facilitated VNSNY's ability to highlight and
institutionalize nursing's role in emergency and postemergency
relief work. Through participation on city, state, and regional
commissions, we have formalized the role of nursing in the

standards for community response. Within the policy briefings
that have been forthcoming from this event, community nursing
stands embedded along with the environmental, health and
human services, housing, communications, and transportation
responses that impact societal resiliency.
Recognizing that the goals of the Triple Aim and the promise of
the ACA depend on this commitment to community, the VNSNY
made an intentional decision to transform the system of care in
our market by enhancing the competency of our nurses to
address both the individual and population health. Through a
partnership with Duke University and New York University, the
VNSNY has immersed cohorts of its nursing staff in a semester-
long curriculum focused on population care coordination.
Nurses gain enhanced exposure to the constructs of
epidemiology, community assessment, predictive analytics, and
social determinants of health. Armed with these competencies,
nurses are assuming leadership roles in designing and
implementing community anchor initiatives, accountable care
organizations, and payer-based care coordination
infrastructures. Nurses are demonstrating their roles as “…full
partners, with physicians and other health care professionals, in
redesigning health care ...” (IOM, 2010).
Nurses at the VNSNY are using these and other competencies to
weave together a cross-continuum system of care that facilitates
the safe and meaningful passage of patients. National statistics
underscore the imperative for this cross-continuum
coordination. In care for the chronically ill, studies have shown
that only half of the recommended services are provided (IOM,
2010). If the quality of care were to improve in each state to
match that in the highest performing states, an estimated 75,000
lives could be saved each year (IOM, 2012a, 2012b). Care
quality, then, is critical to the path forward and partnerships are
vital to this aim.
the Population Care Coordinator
Shifting from a fee-for-service reimbursement environment to
one that is value-based requires a change in practice among

front-line community health nurses with regard to financial,
quality, and population management concerns. In the past,
reimbursement was based on the number of patients seen and
the particular comorbidities of each patient. Under the value-
based model, payment is based on a number of factors linked to
care quality. Hospitals are penalized when their patients are
readmitted within 30 days of being discharged, and patient
satisfaction scores are measured and reported publicly, which
influences consumer engagement and choice. Community health
nurses must intentionally link discrete interventions to patient
outcomes, most notably by preventing unnecessary
rehospitalizations and by optimizing patient care experiences.
Hospital Partnerships and Transitional Care
The VNSNY has collaborated with health system partners to
establish transitional care programs that facilitate shorter
lengths of stay, mitigate the need for subacute placement, and
significantly reduce first 30-day all-cause readmissions. The
critical components of these programs include: cross-continuum
clinical pathways, interprofessional participation and
endorsement, warm handoffs at the bedside between acute care
and home care nurses, risk adjustment methodologies, and the
leadership of advanced practice nurses.
Nurses in community-based settings are participating in
convening tables with health system partners to redesign the
models of care that are patient-focused and community-centric.
In one 668initiative, hospital length of stay for postoperative
patients recovering from hip and knee replacements was reduced
by 1 day through an interprofessional team effort that included
bedside handoffs, the more effective management and
anticipation of uncontrolled diabetes, the advancement of a
rehab home health aide coach, and the implementation of an
intensive rehab program, which eliminated the need for a
subacute stay. The readmission rate for these patients was under
2%.
In another case of patient postcardiothoracic surgery, warm
handoffs at the bedside between the acute care and the home

care nurse, including focused patient and caregiver engagement,
resulted in avoidance of subacute placement, a reduction in
substernal wound infections, reduction in length of stay,
rehospitalization rates below 10%, and higher patient
satisfaction and caregiver engagement.
Another opportunity for community nursing to transform the
delivery system is to affect the system of care that results in
avoidable emergency department visits with resultant
admissions. By adding a community health nurse to the
emergency department team, the perspectives of the home and
community as assets in the plan of care result in an assess-and-
release approach that is more conducive to patient outcome.
Among 622 patients assessed in the emergency department of
one hospital by VNSNY nurses over a 6-month period, 59%
went home directly rather than being admitted to the hospital.
The community health nurse in the emergency department
interfaces with the home visiting nurse and the community-
based nurse practitioner who stabilize the plan of care and
create the bridge to the primary care provider. This program has
been so effective that new start-up insurance companies on the
New York State Health Exchange are contracting with the
VNSNY so that home care nurses in the emergency department
will be alerted via text when a member of their health plan
arrives in the emergency room.
If nurses are truly to affect the system of care, they must also
impact health insurance companies. Nurses at the VNSNY did
just that by engaging a health insurance company as a partner.
Using a modification of the Naylor transitions of care approach,
the VNSNY nurses and nurse practitioners partnered with a
major insurer and a community hospital to address the incidence
of unnecessary hospitalizations among health plan members.
Members of the interprofessional team included hospital
physicians, nurses, and social workers; VNSNY nurses and
nurse practitioners; and nurse practitioners from the health plan.
Weekly case conferences, including staff from the hospital,
VNSNY staff, and nurse practitioners from the health plan, are

conducted virtually for the establishment of the plan of care.
Members who were hospitalized received a bedside assessment
by a VNSNY nurse to determine their risk of readmission.
Among the variables that drive risk acuity are: multimorbidity,
polypharmacy, cognitive disability, mental illness, substance
abuse, and previous hospitalization or home care admission
within the previous 6 months. For those who exhibit the highest
risk, a VNSNY nurse practitioner enrolls the patient in a 30-day
transitional care program with focused care coordination by an
interprofessional team. The 24-hour access to a nurse
practitioner, which addresses issues such as medication
adjustment, anxiety, and the management of symptoms, many of
which occur disproportionately after hours, has been a gold
standard for this program. This cross-continuum model,
designed by nurses, has effected a 49% reduction in first 30-day
all-cause readmissions.
Vulnerable Patient Study
Recognizing that the ultimate effectiveness of our work in
impacting health care transformation rests on the degree to
which it impacts reimbursement methodologies and policy
considerations, the VNSNY has directed considerable effort to
translating our knowledge of community-based health care to
policy arenas. Through our care of vulnerable community-based
populations, we have found that certain patient characteristics
are predictive of the resource allocation that patients will
ultimately require and that must influence reimbursement
methodologies if these patients are to receive appropriate care.
Through research conducted in partnership with the Visiting
Nurse Associations of America, the VNSNY's Center for Home
Care 669Policy and Research and 23 Visiting Nurse
Associations across the country identified patient characteristics
that are not adequately considered in the Medicare home health
methodology. Those characteristics include: presence of a
caregiver, socioeconomic status, continence, clinical
complexity, and uncontrolled chronic illness.
The results of this study have been shared with the Medicare

Payment Advisory Commission, an independent organization
established by the Balanced Budget Act of 1997, and the
Centers for Medicare and Medicaid Services, which administers
Medicare, Medicaid, and Children's Health Insurance Programs
and coordinates with states to set up Health Insurance
Marketplaces, expand Medicaid, and regulate private insurance
(Centers for Medicare and Medicaid Services [CMS],
2013; Medicare Payment Advisory Commission [MedPAC],
2013). The goal of this advocacy has been to influence risk
acuity of the Medicare system to more adequately address the
needs of vulnerable populations. We are using similar predictive
analytics and risk-adjusted methodologies to negotiate funding
streams with private payers.
Conclusion
As the health care system continues to demand a commitment to
the tenets of the Triple Aim, community health nurses have a
central role to play in transforming the system of care. With a
discipline anchored in an understanding of public health, with a
practice that honors the assets of the community, and with a
relationship-based competency that facilitates partnerships,
community health nursing can and must execute on the IOM call
for our profession to emerge as architects of a transformed
health care system.
Discussion Questions
1. What are the ways in which a population health focus might
be applied in the transforming health care delivery system?
2. What are some of the new constructs that nurses are
integrating in promoting the health of communities?
3. What are the key foundational elements of a successful
transitional care program?
References
Bennett H, Coleman E, Parry C, Bodenheimer T, Chen E. Health
coaching for patients with chronic illness. Family Practice
Management. 2010;17(5):24–29.
Bielaszka-DuVernay C. The “GRACE” model: In-home
assessments lead to better care for dual eligibles. Health

Affairs. 2011;30(3):431–434.
Centers for Medicare and Medicaid Services [CMS]. CMS
strategy: The road forward 2013-2017. [Retrieved from]
www.cms.gov/About-CMS/Agency-Information/CMS-
Strategy/Downloads/CMS-Strategy.pdf; 2013.
Coleman E, Parry C, Chalmers S, Min S. The care transitions
intervention: Results of a randomized controlled trial. Archives
of Internal Medicine. 2006;166(17):1822–1828.
Hospitals in Pursuit of Excellence. Case study: Proven Health
Navigation at Geisinger Health System. [n.d. Retrieved from]
www.hpoe.org/resources/case-studies/1297.
Institute of Medicine [IOM]. The healthcare imperative:
Lowering costs and improving outcomes. National Academies
Press: Washington, DC; 2010.
Institute of Medicine [IOM]. The future of nursing: Leading
change, advancing health. National Academies Press:
Washington, DC; 2011.
Institute of Medicine [IOM]. Public health and primary care:
Exploring integration to improve population health. National
Academies Press: Washington, DC; 2012.
Institute of Medicine [IOM]. Best care at lower cost: The path
to continuously learning health care in America. National
Academies Press: Washington, DC; 2012.
Janosky J, Armoutliev E, Benipal A, Kingsbury D, Teller J, et
al. Coalitions for impacting health of a community: The Summit
County, Ohio, experience. Population Health Management.
2013;16(4):246–254.
Medicare Payment Advisory Commission [MedPAC]. About
MedPAC. [Retrieved from] www.medpac.gov/about.cfm; 2013.
Naylor M, Aiken L, Kurtzman E, Olds DM, Hirschman K. The
importance of transitional care in achieving health
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Online Resources
American Public Health Association.
www.apha.org.
Care Transitions Program (Eric Coleman's Model).

www.caretransitions.org.
Institute for Healthcare Improvement.
www.ihi.org/Pages/default.aspx.
Transitional Care Model (Mary Naylor's Model).
www.transitionalcare.info.
Visiting Nurse Associations of America.
vnaa.org.
.

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