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Today at the American Public Health Association annual meeting in New Orleans, Shirley Orr, MHS, APRN, a Robert Wood Johnson Foundation Executive Nurse Fellow and public health consultant, and Doris Brown of the Louisiana Department of Health, will be talking about opportunities for nursing leaders to implement the recommendations of a 2010 Institute of Medicine Report entitled “The Future of Nursing.” This report looks at ways that the nursing profession can transform itself in order to better align with population health and more effectively collaborate to create a healthier overall population.
NewPublicHealth recently spoke with Orr about how nurses can help improve community and population health. This interview has been lightly edited for clarity and length.
NewPublicHealth: What does the nursing profession need to do in order to align itself with a focus on population health?
Shirley Orr: A couple of things in particular that stand out are education and diversity. We recently did a public health nursing enumeration that was funded by the Robert Wood Johnson Foundation, and we found two things in particular relating to the recommendations. First, that overall, public health nurses need new skills and they need higher levels of education to be able to function more collaboratively and within collaborations—both within health care and with other community partners.
Second, we found that nationwide, the demographic profile of public health nurses does not look like the population that we serve. Ethnic minorities are very much underrepresented among public health nursing—particularly in leadership roles.
We have a very urgent need to recruit more nurses of color into the ranks of public health nursing leadership.
NPH: Why is that necessary?
Orr: A core component of nursing curriculum today is culture competency. That being said, we also know that having nurses who understand populations very, very deeply by having a frame of reference for that population and being a member of that population really are able to help to get the highest level of engagement from the population. They’re also best prepared to understand the culture, the needs, the motivations about populations, so they’re really best positioned to be able to carry out in partnership strategies that are going to make a difference long-term in the health of populations.
Recent data out of California has shown that close to 90,000 children go to the emergency room for dental care each year. Although the cost of those visits is tens of millions of dollars, often little more is done than prescribing antibiotics to control infections. While that is important, after such a visit a child’s teeth remain decayed, posing significant risks for adult dental health problems, which can lead to illnesses, deaths, huge out of pocket costs and reduced job opportunities if teeth are noticeably missing.
But California is now also the first state in the nation to permit dentists to take care of underserved kids and adults virtually. A law passed at the end of September vastly expands the Virtual Dental Home, a demonstration project that uses telehealth technology to bring dental services directly to patients in community settings, such as preschools, elementary schools and nursing homes.
Under the program, dental hygienists and assistants perform preventive care and provide patient information electronically for review by an off-site dentist. Under the direction of the dentist, the providers can also place temporary fillings—no drilling required—which can last for years, according to Jenny Kattlove, an oral health policy analyst for The Children’s Partnership, a children’s advocacy group. Patients who need more advanced care are referred to a dentist, and often they’re the dentist who worked with their technician.
A recent Pew study examined how the Virtual Dental Home worked at an elementary school in Sacramento, where the program provided cost-effective services to low-income children who did not have a regular source of dental care. Care under the Virtual Dental Home is paid for under California’s Medicaid program.
According to research by the University of the Pacific Arthur A. Dugoni School of Dentistry, which operates the Virtual Dental Home pilot program, more than 30 percent of Californians are unable to meet their oral health needs through the traditional dental care system. More than half of California’s Medicaid-enrolled children received no dental care in 2012 and even fewer received preventive care services.
NewPublicHealth recently spoke with Kattlove about the new law and its potential as a model for dental care for low income individuals across the country.
NewPublicHealth: What is the most significant advantage of the Virtual Dental Home?
Jenny Kattlove: The Virtual Dental Home is a way to diversify or disperse the workforce so that all the professionals are working at the top of their skills and expertise. By putting dental hygienists in a community setting and having them take care of the majority of the care that the child needs, the dentist can be in the clinic or in their dental office taking care of the more complex needs and supervising the hygienist.
Earlier this year, Taos Pueblo, N.M., was chosen by the Robert Wood Johnson Foundation (RWJF) as a Culture of Health Prize winner for its efforts to improve community health by declaring self-governance. As part of a new ongoing series, Health Affairs blog has featured a piece by local Taos Pueblo leader Ezra Bayles on the community’s health successes.
Taos Pueblo is a National Historic Landmark where Native Americans have continuously lived for more than 1,000 years. Approximately 1,350 people call it the sovereign nation home. Despite its concerted efforts to keep its ancient oral language, culture and traditions alive, the community faces serious public health issues that are rooted in high rates of poverty and unemployment. Approximately 47 percent of pueblo youth under age 20 are overweight or obese and 21 percent of its adults have diabetes.
As a means to address these troubling issues, in 2007 the Taos Pueblo Tribal Council took steps toward self-governance, which allowed them to reorganize and streamline community services.
“We’ve taken on even more responsibility and are taking on the programs, functions and services to serve our people,” said Shawn Duran, Tribal Programs Administrator for Taos Pueblo, to NewPublicHealth earlier this year. “We’re finding solutions that we’re familiar with and turning that into programs that work for our people.”
Taos Pueblo’s efforts include:
- Forming the Red Willow Community Growers Cooperative and the Red Willow Farmers Market in order to revive and celebrate the tribe’s agricultural heritage while also providing healthier food options.
- Serving children ages 1 to 5 with the Taos Pueblo Head Start and My First School, which incorporates healthy eating while also instilling a strong sense of community.
- Creating the Public Health Nursing Department, which sends a Native American nurse and two trained Community Health Workers directly to people’s doors as a way to make accessing care easier.
To learn more about Taos Pueblo’s prize-winning efforts to improve health, read the Health Affairs blog post.
>>Bonus Content: Watch a NewPublicHealth video on Taos Pueblo’s efforts to build a Culture of Health.
EBOLA OUTBREAK: WHO Says Ebola is Spreading at a Faster Rate than Health Workers Can Handle
(NewPublicHealth is monitoring the public health crisis in West Africa.)
Earlier this week, the World Health Organization (WHO) announced that the Ebola outbreak in West Africa—the largest in history—shows no signs of slowing down. Today the global health organization followed that by declaring that health officials are currently unable to handle the growing number of cases. "In the three hardest hit countries, Guinea, Liberia and Sierra Leone, the number of new cases is moving far faster than the capacity to manage them in the Ebola-specific treatment centers," said Margaret Chan, the WHO director-general, according to CNN. "Today, there is not one single bed available for the treatment of an Ebola patient in the entire country of Liberia." More than 2,400 people have died from Ebola since the start of the outbreak. Read more on Ebola.
Study: Majority of Nursing Home Residents with Advanced Dementia Receive Questionable Medications
The majority of nursing home residents dealing with advanced dementia receive medications that are both questionable—if not outright ineffective—and cost them needless amounts of money, according to a new study in JAMA Internal Medicine. In a review of 5,406 nursing home residents with advanced dementia, researchers determined that slightly more than half (53.9 percent) received at least one medication with questionable benefit; the medications constituted approximately 35.2 percent of the total cost of care for those patients. According to the researchers, the patients’ goals of care should dictate the treatment they receive when dealing with a terminal illness, and medications that don’t promote that primary goal should be minimized. Read more on aging.
Study: ‘Fat Shaming’ is Counterproductive
“Fat shaming” does not promote weight loss and in fact can be counterproductive, according to a new study in the journal Obesity. In an analysis of nearly 3,000 adults tracked over four years, researchers determined that weight discrimination was associated with a weight gain of approximately 2 pounds, while the participants who reported no fat shaming lost an average of 1.5 pounds. "Our study clearly shows that weight discrimination is part of the obesity problem and not the solution," said the study's senior author, Jane Wardle, director of the Cancer Research UK Health Behaviour Centre at University College London (UCL), in a release. "Weight bias has been documented not only among the general public but also among health professionals, and many obese patients report being treated disrespectfully by doctors because of their weight. Everyone, including doctors, should stop blaming and shaming people for their weight and offer support, and where appropriate, treatment.” Read more on obesity.
Close to fifty college undergraduates got a bird’s-eye view of public health careers this summer during the Summer Public Health Scholars Program (SPHSP), a partnership with Columbia University’s College of Physicians and Surgeons, College of Dental Medicine, School of Nursing and Mailman School of Public Health.
“I’ve learned that public health isn’t just about medicine,” said 2014 participant Richmond Laryea, a junior at the University of Central Florida. “It’s about things like the security and safety of public parks, places for farming, transportation, and education—it really takes place in every sector."
>>Bonus Content: Watch participants in last year’s program talk about their public health internships.
The program, which is funded by the U.S. Centers for Disease Control and Prevention’s Office of Minority Health and Health Equity, is designed to show students the range of public health practice. Students typically spend three days at an internship, one day in the classroom and one day on a field trip to places such as the Harlem Children’s Zone. Each student is also mentored by the Mailman School’s associate dean of Community and Minority Affairs.
Laryea said his career plan is to become a cardiothoracic surgeon, but with some time spent gaining a public health degree, as well.
“With my experience in public health, I’ve learned that I want to look into a community approach to help others as a whole, instead of just helping an individual person,” he said.
Public health agencies where students are performing fieldwork this summer include the Northern Manhattan Perinatal Partnership, BOOM!Health, the South Bronx Overall Economic Development Corporation and New York City’s Correctional Health Services.
During this week’s Spotlight: Health at the annual Aspen Ideas Festival, Cleveland Clinic CEO Toby Cosgrove, MD, will be talking about the future of academic medicine. The topic has received a great deal of attention recently, including a white paper from the Bipartisan Policy Center (BPC) and a pilot program from the American Medical Association (AMA) to give $1 million each to eleven medical schools redesigning their teaching programs—many of which include a focus on prevention, wellness and population health.
Teamwork is a recent and critical emphasis at the Cleveland Clinic Lerner College of Medicine, said Cosgrove in a conversation with NewPublicHealth ahead of the Aspen conference.
“When a lot of us went to medical school we were all taught to be rugged individuals, and so [now] we’re trying to teach teamwork...at the very beginning of health care education,” he said. To that end, instruction at the medical school now emphasizes team-based learning and the students will begin doing some of their work with nursing and dental students in the same physical facility “so we begin to break down the silos that are going on right now and encourage team play.”
The 11 medical schools that received the recent AMA grants were chosen from among 119 schools that submitted proposals. “Their bold, transformative proposals [are] designed to close the gaps between how medical students are trained and how health care is delivered,” said former AMA President Jeremy A. Lazarus, MD, when the AMA awarded the grants last year. Among the winners:
- The Alpert Medical School of Brown University, which has proposed establishing a dual MD-MS degree program in primary care and population health. A clerkship during the third year of medical school will integrate care of the individual patient and population health, and the fourth year will include population health course content and require a Master's thesis. The admissions process will include required interviews with stakeholders and patients.
- The University of California-Davis School of Medicine is partnering with Kaiser Permanente to create the Accelerated Competency-based Education in Primary Care (ACE-PC) program, which will require all students to work in the Kaiser Health system so that they can learn by experiencing the patient-centered medical home model. Changes to curriculum include population management, chronic disease management, quality improvement, patient safety, team-based care and preventive health skills, with a special emphasis on diverse and underserved populations.
The eleven schools won’t be working in silos, either. Susan Skochelak, MD, the AMA’s group vice president for medical education, told NewPublicHealth that the initiative was designed “very specifically to bring the schools together in a consortium, because we wanted to disseminate the best practices rapidly.”
CDC: American Indians, Alaska Natives Have 50 Percent Higher Death Rates than Non-Hispanic Whites
American Indian and Alaska Native (AI/AN) death rates were approximately 50 percent higher than rates among non-Hispanic whites—for both men and women—from 1999 to 2009, according to a new study in the American Journal of Public Health. The study determined that patterns of mortality were strongly influenced by the high incidence of diabetes, smoking prevalence, problem drinking and health-harming social determinants. Among the findings:
- Among AI/AN people, cancer is the leading cause of death followed by heart disease. Among other races, it is the opposite.
- Death rates from lung cancer have shown little improvement in AI/AN populations and AI/AN people have the highest prevalence of tobacco use
- Suicide rates were nearly 50 percent higher for AI/AN people
- Death rates from motor vehicle crashes, poisoning and falls were two times higher among AI/AN people
- Death rates were higher among AI/AN infants
“The Indian Health Service is grateful for this important research and encouraged about its potential to help guide efforts to improve health and wellness among American Indians and Alaska Natives,” said Yvette Roubideaux, MD, MPH, acting IHS director, in a release from the U.S. Centers for Disease Control and Prevention. “Having more accurate data along with our understanding of the contributing social factors can lead to more aggressive public health interventions that we know can make a difference.” Read more on health disparities.
FDA Proposes New Program to Help Patients With Unmet Tech Needs
The U.S. Food and Drug Administration (FDA) has proposed a new program designed to help treat or diagnose people with serious conditions, but whose needs aren’t met by current technology. The proposed Expedited Access Premarket Approval Application for Unmet Medical Needs for Life Threatening or Irreversibly Debilitating Diseases or Conditions (“Expedited Access PMA” or “EAP”) program would include earlier and more interactive engagement with FDA staff, with the goal of providing patients with earlier access to safe and effective medical equipment. “The program allows manufacturers to engage early and often with the agency,” said Jeffrey Shuren, MD, director of the FDA’s Center for Devices and Radiological Health. “We expect most devices that enter this program will be in the pre-clinical trial phase.” Read more on technology.
Study Links Internet Use, Lower Depression Rates in Older Americans
Older Americans who spend more time online are also less likely to suffer from depression, according to a new study in The Journals of Gerontology: Series B. Using data on 3,075 retired men and women who didn’t live in nursing homes gathered by the U.S. Health and Retirement Survey, researchers determined that the 30 percent who were Internet users also had a 33 percent lower probability of depression. "The largest impacts on depression were actually for those people who lived alone, so it's really suggesting that it's about connecting with others, eliminating isolation and loneliness," lead study author Shelia Cotton, according to Reuters. Read more on aging.
Rockingham County, N.C., is one of several counties profiled in videos produced for the 2014 report of the County Health Rankings, a joint project of the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute, and released yesterday. The Rankings shows how communities across the country are doing and how they can improve on their health.
Rockingham evolved from a wealthy county to a poor one very quickly after losing two major industries only a couple of decades ago. The community suffers from high general smoking rates, high obesity rates and high rates of smoking during pregnancy. When the 2010 County Health Rankings were released, Rockingham was ranked at 71 out of 100 counties on health measures. The community's poor standing served as a wake-up call.
One new program set to begin this spring is the Nurse-Family Partnership, a decades-old, evidence-based community health program that serves low-income women pregnant with their first child.
Nurse-Family Partnership is based on the work of David Olds, MD, a professor of pediatrics, psychiatry and preventive medicine at the University of Colorado Denver. While working in an inner-city day care center in the early 1970s, Olds was struck by the risks and difficulties in the lives of low-income children and over the next decades tested nurse home visitation for low income families in randomized controlled trials in Elmira, New York, Memphis, Tennessee and Denver. Results have shown that the program improved pregnancy outcomes; improved the health and development of children; and helped parents create a positive life course for themselves. There are now Nurse-Family Partnership programs in 43 states, the U.S. Virgin Islands and six Indian tribal communities.
In the Nurse-Family Partnership programs, the mothers receive ongoing visits from the nurses in their homes from the first trimester until the baby is two years old. Program goals include:
- Improve pregnancy outcomes by helping the new mothers engage in good preventive health practices, including comprehensive prenatal care from their healthcare providers, improving their diets and reducing their use of cigarettes, alcohol and illegal substances.
- Improve child health and development by helping parents provide responsible and competent care.
- Improve the economic self-sufficiency of the family by helping parents develop a vision for their own future, plan future pregnancies, continue their education and find work.
According to Heather Adams, executive director of the Rockingham County Partnership for Children, there are about 5,000 children under the age of five in Rockingham County. Over half live in poverty and are born to mothers under the age of 20 and many of the children are in single parent households.
“The County Health Rankings really gave us some concrete data to show us what we knew anecdotally was really true,” said Adams. “Nurse-Family Partnership really rose to the top as a really strong program that could help meet some of our needs.”
As part of its County Health Rankings coverage, NewPublicHealth recently spoke with Elly Yost, MSN, PNP, director of nursing practice at the Nurse-Family Partnership national office in Denver, Co. Yost is a pediatric nurse practitioner who previously worked in hospitals and community practice settings.
Study Finds Many Older Adults Often Not Prepared for Disasters
A recent University of Iowa study finds that, compared to younger adults, older adults are more vulnerable when natural disasters, hit yet most U.S. adults ages 50 and older may not be prepared for a serious flood, earthquake, tornado, or other natural disaster. The report is based on a 2010 survey that was part of the Health and Retirement Study, which collects social, economic, and health information on adults age 50 and older in the United States. The survey did not include older adults living in nursing homes or other institutional settings. Among the findings:
- Only about one-third of the 1,304 adults interviewed said they had participated in an educational program or read information on how to prepare for a disaster.
- Fewer than 25 percent had an emergency plan in place, although the same percentage lived alone.
- Almost one-third reported being disabled or in fair or poor health.
“Our analysis underscores that older adults living at home often have special needs and situations that put their health and safety at risk in the face of natural disasters,” said Tala Al-Rousan, MD, the study’s primary author and a graduate student in epidemiology at the UI College of Public Health. “The oldest respondents, 80- to 90-year-olds, were significantly less prepared than 65- to 79-year-olds.”
>>NewPublicHealth will be on the ground at the 2014 Preparedness Coverage this week. Follow our coverage here.
Healthy Foods Can Increase Concession Stand Sales A new small study by researchers at the University of Iowa found that adding healthy foods to a football game concession stand appears to increase sales. The researchers asked a college club to add healthy foods such as apples and string cheese to its concession stand menu open during football season, as well as put healthier ingredients into other items including nachos and popcorn. Sales rose four percent over the previous year, and the healthier foods making up almost ten percent of sales. The study was published in the Journal of Public Health. Read more on nutrition.
Study: Gastric-Bypass Surgery Linked to Remission of Type 2 Diabetes
People who undergo gastric-bypass surgery to deal with their weight are more likely to see their type 2 diabetes go into remission without medication that are people who undergo a sleeve gastrectomy, according to a new study in the New England Journal of Medicine. "One-third [of patients] in the gastric bypass group had remission of diabetes—meaning they had normal blood sugar control—and a quarter of the people in the sleeve gastrectomy group had remission of type 2 diabetes," said study co-author Sangeeta Kashyap, MD, an endocrinologist at the Cleveland Clinic's Endocrinology & Metabolism Institute, according to HealthDay. "These effects are real, and they're persistent for at least three years. Essentially, these patients have had a vacation from diabetes for three years." The study included 150 people with type 2 diabetes, with an average age of 49 and two-thirds female. Read more on obesity.
Louis W. Sullivan, MD, former U.S. Secretary of Health and Human Services under President George H.W. Bush, recently wrote a memoir, Breaking Ground: My Life in Medicine, that offers a wide view of Sullivan’s experiences as a medical student in Boston, the founding dean of the Morehouse School of Medicine in Atlanta and as the country’s chief health officer. NewPublicHealth recently sat down with Sullivan to discuss the book and his thoughts on the history and future of improving the nation’s health.
NewPublicHealth: Looking back, what can you share about the highlights of your career in medicine and health promotion?
Louis Sullivan: Highlights would certainly include my time at the Boston University School of Medicine. That had many significant points. It was my first time living in an integrated environment because up until that time I spent all of my life in the South. Working in an environment without concerns about discrimination and bias, that was a great experience; my classmates and the faculty at Boston University were all welcoming.
Another highlight was later when I was a research fellow in hematology in the Harvard unit at Boston City Hospital. I had a paper accepted for presentation at a major research conference in Atlantic City. It was a paper showing that heavy drinking suppressed the production of red blood cells by the bone marrow.
And of course a tremendous highlight was going back to Morehouse College, my alma mater, to start the Morehouse School of Medicine. I was returning home in a sense. I had gained experience as a faculty member at Boston University, had been steeped in medicine and now I was in the process of establishing a new institution to train young people for the future.
NewPublicHealth: What changes have you created and supported to improve population health.
Sullivan: Well, certainly becoming Secretary of Health and Human Services was indeed an honor and a great opportunity for me, and it was also a very challenging experience.
In the late ‘80s, when I became Secretary, AIDS was a new disease. There were many demonstrations by various advocacy groups, groups that didn’t trust the government, and we had to work to develop a relationship with them. I convinced President Bush to put $1.6 billion in his budget to be used for research on this new disease, to develop mechanisms for treating the disease and to educate the public. And as a result of that initial investment and ones that followed, this disease has been transformed from a virtual death sentence to a chronic disease which is controlled by medication. And people, rather than living a few months, which was the case once the diagnosis was made in 1989, are now living for decades with the virus suppressed on medication, raising their families, working, earning wages, paying taxes. So that has been really a very satisfying outcome from that experience. And we hopefully are close to finding a cure for this disease as well.