Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: SUNDAY, May 2, 1993 TAG: 9304280445
SECTION: NURSES PAGE: 12 EDITION: METRO
SOURCE: By SARAH COX
DATELINE: LENGTH: Long
Sandy Moore is a public health nurse supervisor for the Roanoke City Public Health Department. Moore's specialities are child and school health. She works with nurses employed through the Chapter 1 program, as well as with other public health nurses who are assigned to city schools.
Moore said school nurses no longer simply hand out Band-Aids. "Roles have been expanded. We are now resources to the administration and teachers on health issues," she said.
Moore said they identify health problems, contact the parents or even make a home visit. They also serve as community resource information centers.
"Sometimes it just takes a nurse working with a parent, one-on-one. A lot of times I have worked with parents who have no health insurance," she said.
According to the Virginia Nurses Association, there are more than 20,000 children in the state with no health care provider. They use the school nurse as a link to medical resources.
Moore, in testimony presented in February to the Virginia Senate Education and Health Subcommittee, said that in Roanoke City there are over 4,000 children who lack access to comprehensive health care. "Our school nurses have seen a dramatic increase in the health needs of our school-age children," she said.
"We also try to be involved in early age health promotion and lifestyles," said Moore. For instance, at a teacher's request, a school nurse may make dental and personal hygiene presentations; and teach nutrition, family life education; about communicable diseases and how to avoid them (such as washing hands and blowing noses) and even how the heart works.
"With present staffing levels, we don't have enough time to do that. In our health department, we have 10 nurses with school assignments, but they also have other assignments. School health is not mandated with the State Department of Health," she explained.
Moore added that six more part-time school nurses are funded through the federal government's Chapter 1 program, but that may not continue. In November, 1992, Moore said the Roanoke City School Board voted to add four more nurses to the system each year for the next four years. "That will help us meet the state legislative studies,"` which recommend one nurse for every 1,000 students, she said. Now, the Roanoke City ratio is approximately one registered nurse per 4,200 students.
"The problem has been trying to find funding to meet expectations. The school system learned in early April that Chapter 1 will probably not be funding the six part-time nurses again. I would certainly like to see one nurse for every 1,000 students - and ideally, one in every school. I think we'll see, with Clinton's interest in health care reform, federal initiatives for funding. And I'd like to see legislation passed in Virginia to meet state legislative recommendations.
"As the situation is now, illnesses and injuries occurring at the school are left to the secretary or administration to assess the problems. Many have had first aid courses, but may not recognize certain symptoms," Moore said.
Linda Rickabaugh also supports health care reform. As a matter of fact, one would be hard pressed to find a nurse that did not. Rickabaugh sees it from a different perspective, though - she's director of Nursing Education at the College of Health Sciences, and has been since 1989.
"Any nurse that goes into the hospital and sees how things have changed, especially the technology and the cost that go along with that, and sees people that can't pay - that hits nurses," Rickabaugh said.
She remembers last year witnessing several hospital patients leaving the same day after surgery which normally would require several days in the hospital because they were underinsured.
Policymakers, said Rickabaugh, need to get in touch with the people in the front lines - certainly nurses, and certainly health care providers.
"People making decisions are not as well educated as health care providers," she said.
Rickabaugh said she believes physicians are "getting a bad rap - they are being cut out, and they're still primary providers of care. We're cutting off our noses to spite our faces - we do need to listen to the point of views of all health care providers," she said.
Another component of health care reform Rickabaugh is involved with is increasing the level of quality and competence among nurses.
"I work with a statewide group that the Virginia Hospital Association organized which addresses the issues of service," she explained. Rickabaugh said educators are meeting to examine competency of newly graduated registered nurses.
Another factor involved is increasing the quality of the RN. "We have to build on their strengths. Nurses realized that we should work together, to develop more flexible career pathways and to help nurses move up the ladder," she said.
Becky Luther presents yet another point of view on health care reform. She is a Child Health Invest Partnership, or CHIP, nurse. This program is a public-private partnership funded by a series of grants, and it acts in three different ways. First, it acts as the primary health care provider to children through participating pediatricians and family practitioners, thus giving children continuous as opposed to fragmented care. Secondly, CHIP does case management by assessing and enrolling children, below the 133 percent poverty level who are age-appropriate (birth to age 6), and a nurse is assigned to a family to act as a care coordinator. And thirdly, it provides family related services and makes agency referrals.
Luther sees a segment of the population that needs health care reform.
"I certainly do feel that reform is needed - young children probably are the largest segment that need this. It's important to increase the access, prevent diseases and help minimize developmental delays caused by poor health care," she said.
Luther says educating the public is one of the largest stumbling blocks that could be tackled with health care reform.
"You can provide access, but that doesn't mean they're going to go get health care. I see, especially with public health nurses, that education is one of the biggest things we do for families, particularly preventative health care. You've got to address the family as a whole. Our goal is that at least 90 percent of all enrollees are up to date on immunizations, well check-ups and dental care," Luther said.
CHIP's director and its first nurse, Peggy Balla, has been part of several health care conferences on children poverty and health care, and the success of CHIP has resulted in this program being duplicated in Chesapeake, Abingdon, Charlottesville and Richmond, with three other sites in the New River Valley, Norfolk and Williamsburg in the planning stages. There are 1,100 enrolled in Roanoke's program now, and according to Luther, the potential throughout the Roanoke Valley is 5,000.
Balla sees health care reform shaping up in the form of a basic federal package that will be individualized on the state level. She predicts community planning, recruitment for more mid-level practitioners such as nurse practitioners, and turning out more primary care physicians.
"We may see more incentives, and may need to put a cap on the number of residencies of specialty care. We may need to rethink the way we train everybody - we may need a cross-fertilization between nurses and doctors. And we need to look at barriers: transportation, financing, building a provider base, reimbursement system and educating families. CHIP is a new way of delivering services to women and children, and the case management with parental support is a good way to coordinate public services," she said.
Non-duplication of services is important, "but you also begin to realize what services are not out there. I think everybody in health care is wondering what is going to happen. On the other hand, I don't know that with women and children, we can wait," she said.
Primary and preventative care emphasis, Balla predicts, will come into their own in the future. And cost containment is an integral part of the debate.
"After all, that's what started this whole health reform anyway," Balla said.
Jean Allman knows about cost containment. She's vice-president of Patient Care at Radford Community Hospital, the third-largest hospital in the Carilion Health System. When asked how she felt about health care reform, she cited three areas of importance: shifting nursing roles, managed care and the organizational reforming to a patient-focused care.
"The nursing challenges for the '90s and beyond is how to best redesign health care for better quality and lower cost outcome; these outcomes need to be responsive to patient needs. The new game in health care is that change is the only constant. If you look at the traditional health care, things were very predictable, but because health care continues to grow in complexity, especially with technology, change is inevitable," Allman said.
The moral and ethical question, said Allman, is how to achieve better for less.
"Health care of the future is health care delivered with fewer resources, and that's where reform looks critically at how services are delivered," Allman said.
She predicts we will move from a bureaucratic model to a transformational model, where actions within a hospital will be clarified, simplified and centralized according to like demands.
For example, streamlining care delivery means clustering patients by resource utility and intensity of care, and redeploying patient technology into work stations. Redeploying ancillary services in the hospital of the future will mean training a unit's staff to handle just about everything, from admissions to blood work to EKG and IV therapy, so that they will be more skilled (more marketable) and there will be less downtime.
"Over a typical three- to four-day hospital stay, a patient comes into contact with 50 to 60 staff members. What you're going to do is bring people to one focal point. For the RN, you'll have cross training," said Allman.
The new attitude will be to first satisfy the patient, then, please the practitioner, said Allman. By centralizing care, hospitals can reduce the length of a patient's stay without letting releasing the patient too soon. Many times, admission paperwork and testing are done the day before an operation. With clustering, it can all be taken care of immediately, on the admitting unit.
In addition, Allman suggested managed care where nurses will become multiskilled and increase a patient's well-being and satisfaction.
"We will be moving from labor-intensive systems to a patient-focused care. Studies indicate that highly specialized care givers spend 40 percent of the time in non-patient care," she said.
Allman, who says health care is long overdue for patient-centered care, is in the midst of reform herself. Radford Community Hospital has engaged Booz/Allen Consultants to assist in redesigning its care delivery model, to incorporate it into a new hospital being built near Interstate 81. This new care delivery model can be seen in only six to eight hospitals nationwide, said Allman, but Carilion hopes to use Radford Community Hospital as a testing grounds.
"We'll be spending more time with our consumers, asking them what they expect when they come into a hospital. When the patients will be satisfied, we'll all benefit," she said.
by CNB