Six libraries in downtown Tucson, Arizona, have some unexpected new employees: public health nurses. In what many believe to be a first-of-its-kind program, Pima County libraries teamed up with the county Health Department to start a jointly-funded “library nurse program.”

Libraries across the country often serve patrons living without shelter, health insurance, medical care or computer access, the Arizona Daily Star reports. As the need for health care and social services has grown in recent years due to a faltering economy and high unemployment, leaders in Pima County were inspired to provide more than just books to their patrons.

Now, five Pima County public health nurses divide the equivalent of one full-time public health nurse position among themselves, working weekdays at six local libraries. The nurses wear stethoscopes so they can be easily identified, but mostly provide health education and referrals to other health care resources in the area rather than actual medical care.

In addition to helping patrons get the health information they need, the program has also reduced the number of 911 calls from the libraries, “partly because nurses trained library staff to recognize when behavioral issues are escalating and to intervene appropriately,” Nurse.com reports.

“If I weren’t here, I think a lot of these individuals would fall through the cracks,” Daniel Lopez, one of the “library nurses” told Nurse.com. “I can open doors for them and they can walk on through. Overall, I think it makes for a healthier Pima County.”

Read more about the library nurse program from the Arizona Daily Star, Nurse.com, and the Today Show.

Nicholas Stine, MD, and Dave Chokshi, MD, MSc, writing on behalf of the New York Academy of Medicine Primary Care and Population Health Working Group.

The New York Academy of Medicine is the National Program Office for the Robert Wood Johnson Foundation Health & Society Scholars program, which works to reduce population health disparities and improve the health of all Americans. The New York Academy recently conducted a survey of 17 thought leaders in primary care and population health. In the final of five blog posts, we share a synthesis of what those leaders had to say. All quotes are printed with permission.

Addressing Social Determinants of Health: Given the current state of the clinical delivery system, it may seem unrealistically burdensome to ask health care institutions to address the social determinants of health (SDH). “In this country it’s an accomplishment if you can reward value for delivery,” noted Arnold Milstein, MD, MPH, “and social determinants approaches are a step or two beyond that.”

Examples of clinical engagement in social determinants, however, can be quite impactful:

·         Lloyd Michener, MD, and Bob Lawrence, MD, described how Duke and Johns Hopkins both invested in SDH initially in order to repair or promote their public image. For example, Duke invested in some SDH programs and community partnerships in part to help repair their image in the setting of poor relationships with a minority, low-income community in Durham—though these investments have grown into more lasting partnerships. 

·         David Stevens, MD, pointed out the example of the 16th St Community Health Center in Milwaukee, where an environmental wing of the health center was created to combat lead poisoning—and then expanded over years into broader projects, such as combatting brownfields and creating green spaces for exercise.

Nicholas Stine, MD, and Dave Chokshi, MD, MSc, writing on behalf of the New York Academy of Medicine Primary Care and Population Health Working Group.

The New York Academy of Medicine is the National Program Office for the Robert Wood Johnson Foundation Health & Society Scholars program, which works to reduce population health disparities and improve the health of all Americans. The New York Academy recently conducted a survey of 17 thought leaders in primary care and population health. In the fourth of five blog posts, we share a synthesis of what those leaders had to say. All quotes are printed with permission.

The Role of Primary Care and Clinical Incentives: Most discussants agreed that primary care and the patient-centered medical home (PCMH) movement are important foundations upon which to build broad-based population health activities. While acknowledging that these systems are already over-burdened with clinical responsibilities—and that current incentive structures are poorly aligned to accomplish this goal—many cited the degree of overlap in the missions of primary care and public health institutions as a starting point.

Community Care of North Carolina (CCNC), for example, evolved slowly and steadily over 25 years from a clinical quality network to a statewide multi-sectoral public-private partnership based on the PCMH. Allen Dobson, MD, described the key components as: the formation of cooperative provider networks; introduction of population management tools; case management; and data infrastructure with rapid feedback to providers. “Community Care is bottom-up and physician-led with respect to quality improvement…but because the collaboration includes the public health department, we are also looking at population metrics regardless of whether or not we’re managing that population.” Financing is organized using flexible per-member-per-month allotments that allow networks to put resources into quality measurement.  Dobson cited external evaluations demonstrating that the overall project is cost-saving, with CCNC responsible for nearly $1.5 billion in lower costs from 2007-09.

Nicholas Stine, MD, and Dave Chokshi, MD, MSc, writing on behalf of the New York Academy of Medicine Primary Care and Population Health Working Group.

The New York Academy of Medicine is the National Program Office for the Robert Wood Johnson Foundation Health & Society Scholars program, which works to reduce population health disparities and improve the health of all Americans. The New York Academy recently conducted a survey of 17 thought leaders in primary care and population health. In the third of five blog posts, we share a synthesis of what those leaders had to say. All quotes are printed with permission.

Local and State Health Department Collaboration: Most discussants agreed that clinical systems and health departments use different notions of ‘population’—and historically are not well integrated. As David Stevens, MD, noted, “There’s capacity that needs to be built on a common language on how to work together that isn’t there because they've been separated so long.”

There was, however, a prevailing notion that this dynamic is changing in important ways. Many cited the convergence of IRS Community Health Needs Assessment (CHNA) requirements and new public health accreditation standards as a potential blueprint for future collaborations. Clinical delivery systems, generally well-resourced but with limited community assessment and intervention skills, are now responsible for conducting a CHNA every three years while developing and implementing an action plan to address identified needs.

Nicholas Stine, MD, and Dave Chokshi, MD, MSc, writing on behalf of the New York Academy of Medicine Primary Care and Population Health Working Group.

The New York Academy of Medicine is the National Program Office for the Robert Wood Johnson Foundation Health & Society Scholars program, which works to reduce population health disparities and improve the health of all Americans. The New York Academy recently conducted a survey of 17 thought leaders in primary care and population health. In the second of five blog posts, we share a synthesis of what those leaders had to say. All quotes are printed with permission.

Challenges in the Urban Context: Discussants converged upon care fragmentation and community diversity as the most difficult challenges associated with working in urban settings. There may be enormous heterogeneity within populations in urban areas with respect to racial, ethnic, and sociodemographic characteristics. Subgroups may vary with regard to exposures, behaviors, and values. The sense of community that can be essential to leveraging social groups may not necessarily be present or uniform throughout a geographic area, necessitating multiple tailored communication strategies. Even between cities, there is significant heterogeneity, such that non-clinical interventions may be less transferable than, say, a chronic disease model.

Communities that do exist may not necessarily conform to geographic boundaries, and the geopolitical boundaries and layers of jurisdiction in place may mean little to those communities. This changes how confident clinical systems can be for outreach and aspects of care that might reach beyond the office, and in general it can be particularly challenging to know what services are being provided for a patient, where, and by whom. This accountability problem makes it easier for high-risk patients to fall through the cracks.

Nicholas Stine, MD, and Dave Chokshi, MD, MSc, writing on behalf of the New York Academy of Medicine Primary Care and Population Health Working Group.

The New York Academy of Medicine is the National Program Office for the Robert Wood Johnson Foundation Health & Society Scholars program, which works to reduce population health disparities and improve the health of all Americans. The New York Academy recently conducted a survey of 17 thought leaders* in primary care and population health. In the first of five blog posts, we share a synthesis of what those leaders had to say. All quotes are printed with permission.

Defining Population Health: Many discussants cited the definition of population health developed by David Kindig, MD, PhD, as a reference point: “health outcomes of a group of individuals, including the distribution of such outcomes within the group.” Regardless of specific vantage point, there was a generally shared sentiment that population health should be thought of broadly and in common terms by a range of clinical and non-clinical stakeholders.

More discussants described a baseline framework of a clinical delivery system oriented around patients in a practice, in contrast with a public health system oriented around geographic communities. A more clinical, or “population medicine,” perspective often centered around evidence-based interventions and disease management categories so as to triage and allocate health care resources in a cost-effective manner.

Susan B. Hassmiller, PhD, RN, FAAN, is the Robert Wood Johnson Foundation Senior Adviser for Nursing and Director, Future of Nursing: Campaign for Action. This post is part of the "Health Care in 2013" series.

It is a time of year when we celebrate, reflect and make resolutions.  When I think about the nursing community, there is so much that makes me proud.  I am proud of all the ways nurses care for patients. I am proud of how we are adapting to a fast-changing health care system. I am proud of the ways we work effectively in interdisciplinary teams.  And I am proud of the many ways we organize to make our health care system work, especially for the most vulnerable patients.

Following the heartbreaking tragedy in Newtown, Connecticut, with such devastating loss of life, I was so proud to see that 30 major nursing organizations…and probably more now…came together in one collective voice to advocate to the highest public officials in our land on behalf of all those who need our care. The “call to action” from leading nursing organizations meant that, once again, we took a united stand, as nurses, to proclaim that we care…and we will speak out about what must be done on behalf of the people who put their trust in us. 

This made me proud to be a nurse.  And it makes me proud to know that we are asking nurses to speak out and effect change as part of the Future of Nursing: Campaign for Action.  We are asking that the nursing community come together, not for their own benefit…but on behalf of the people and patients who need nurses the most. 

Kelly Buettner-Schmidt, MS, BSN, is executive director of Healthy Communities International at Minot State University, and a doctoral fellow with the Robert Wood Johnson Foundation (RWJF) Nursing and Health Policy Collaborative at the University of New Mexico. She has been awarded numerous grants for her work on tobacco control policy. This post is part of the "Health Care in 2013" series.

This is an exciting time for the U.S. health care system or, as I prefer to call it, the U.S. health system (because health “care” system limits what one includes as part of the “system”). As a public health professional for nearly 30 years—about 20 years as a frontline public health nurse, and now 10 years in academia—I have discovered the need to educate people on all that the state and federal public health systems do to improve the health of not only individuals and families but also communities.[i] [ii]

More than half of my professional career, both as a practitioner and academic, has focused on tobacco prevention and control policies.[iii]  Professional and nursing colleagues, acquaintances, friends, and family often think of my work in tobacco control policy as separate from my public health nursing career. The reasons for this, I believe, are at least two-fold. First, nursing is often equated with direct client care; second, the tobacco industry effectively confuses many into believing the science of tobacco control is controversial and thus spending public health and tax dollars on tobacco control seems wasteful to the public. (As an aside, many nurses are involved in tobacco control. Please join us!)[iv],[v],[vi]

Tiffany D. Joseph, PhD, is a Robert Wood Johnson Foundation (RWJF) Scholar in Health Policy Research at Harvard University (2011-2013).  This post is part of a series in which RWJF scholars, fellows and alumni who are attending the American Public Health Association annual meeting reflect on the experience.

It was incredibly exciting to attend the American Public Health Association (APHA) meeting for the first time! As a sociologist and current RWJF Health Policy Research Scholar, I am thrilled to be at a multidisciplinary conference with an explicit focus on all aspects of health: outcomes, disparities, coverage, service utilization. You name it, there is a session for it.

The opening was especially motivating and inspiring as Dr. Reed Tuckson and Gail Sheehy provided insightful talks on the relevance of preventive health throughout the life course and how public health professionals must continue to work to improve access to, and quality of, health care for a U.S. population that is increasingly racially, ethnically, and socioeconomically diverse.

U.S. Representative Nancy Pelosi also stopped by, unannounced, to welcome the APHA to San Francisco and thank its members for their steadfast commitment to, and support for, passage and implementation of the Patient Protection and Affordable Care Act (PPACA or ACA).  Needless to say, everyone in attendance was thrilled and excited by her surprise visit and warm words.

Robert Otto Valdez, PhD, is the Robert Wood Johnson Foundation (RWJF) professor of family & community medicine and economics at the University of New Mexico. He serves as executive director of the RWJF Center for Health Policy at the University of New Mexico, a national program office for increasing diversity in health and health care leadership. This post is part of a series in which RWJF scholars, fellows and alumni who are attending the American Public Health Association annual meeting reflect on the experience.

The 140th Annual Meeting of the American Public Health Association (APHA), the nation’s oldest gathering of public health professionals in the world, concluded yesterday as the San Francisco region celebrated the World Series victory of their beloved Giants.  Close to 13,000 public health professionals came together around the theme, Prevention and Wellness Across the Life Span.

The closing session focused on incarceration, justice, and health with a keynote speech by Angela Davis.  Our society has used mandatory sentencing and incarceration of Black and Latino young men and, more recently, immigrants as a form of social control that not only maintains the current social order but also contributes to the inequalities in health that result from inequitable society.

The kinds of mass incarceration costing some $70 to $100 billion a year has produced social inequalities that can be readily seen in the lives and families of the formerly incarcerated.  Bruce Western and Becky Pettit offered an insightful article in the Summer 2010 Daedalus that describes the creation of a group of social outcasts “who are joined by the shared experience of incarceration, crime, poverty, racial minority, and low education.”  These are all characteristics that contribute to social and economic disadvantage not only for those who were incarcerated but also their families.