jhoonk

I should have said 'millions of years ago' when there was just one continent on the planet Earth... My point was and is that even to a person like me, new to the abused history of a community, it seems odd there are so many tribes and nations that it is difficult to see a unity within NAIs as a whole. So nobody can suggest how an outsider can help in an NAI nation without being torn apart? Do you as nurses do anything about it? I mean, the almost highest rate of DM, CVD, addiction... Amitai.

Hi, I can't believe this thread is two years old and people are still doing this! I am not an NAI. But as a nursing student, I learned the most abusive and discriminating treatment done to NAIs. And I want to work for NAIs in the future in some capacity. Right now, I don't know how to. You guys let me know if you know how a uninformed non-NAI nurse can help NAI community to raise their health standard and prevent DM, HTN, injury, accident, addiction, suicide etc. I can tell you this. Greenlanders, Alaskans, NAIs, central American Indians, and even myself, Korean, have all in common. We are all from the same kind, ural altai mogolian from thousand years ago. Anyway, I know at least why this blood is important for NAIs because Indian Health Service covers health care by their percentages of pure NAI heritage, right? Are you going to talk about how to improve health care for NAIs or is there another thread? Amitai.

wow, amazing thread, more than 3 years now? Gen, you are a trooper! I haven't checked this thread for a while so I assume you are an MSN, RN, now? Ortho doing what? What happened to other old timers? Did they graduate? Jess and ... Five more months to go for me to be an MSN. Amitai.

Minty80 et. al, This thread explains the CNL role most accurately. Other threads have people, not being aware of CNL's, complaining about it even before they graduate! CNL is completely different concept than CNS or NP. Yes, CNLs need to be expert clinician in their field and they will be in a few years, but the education for CNL is to help them see the health care as a whole, as a system. Nursing shortages come from the system and CNLs will help units increase attrition rates and improve patient outcome. No, they are not charge nurses, not case managers, not CNSs. And yes, they will jump in to help out other nurses and work 100% clinically. They are definitely not nurse managers. Right now, even schools who have these programs do not have any ideas how these new CNLs will change the nursing fields. It all depends on the nursing and hospital administrators who have visions and hopes that nursing field should and can change. (yes, we can! ;-) This is an example of CNL education, in this case community nursing, that has broadened one CNL student's perspective on community health care: http://healthydanes.blogspot.com/ Not that it was necessary for CNL education but it was an experience that money couldn't buy, whether you are a CNL student or non-CNL student.

Poverty and shortage of affordable rental housing are two major reasons for homelessness in the United States. When limited resources have to cover housing, food, childcare, health care, and education, often it is paid for housing that must be dropped. With unexpected illness, accident, or job loss, it is easy for a poor person to end up on the streets. Eroding employment opportunities and the declining value and availability of public assistance are two factors that account for increasing poverty. Between 1970 and 1995, the gap between the number of low-income renters and the number of affordable housing units has increased from zero to a shortage of 4.4 million housing units. A recent strong economy has caused soaring rents but the income of low-income households has never caught up with the rising rents (NCH Fact Sheet #1, 2007). Other factors of homelessness include lack of affordable health care, domestic violence, mental illness, and addiction disorders. A poor individual with serious illness or disability might lose a job, deplete the savings to pay for care, and finally get evicted from the housing. Battered women who are poor often choose homelessness rather than abusive relationships. About 16% of the single adult homeless population suffers from either severe or persistent mental illness. Many patients were released from mental hospitals in the 1950s and 1960s to the community, but dramatic increase in homelessness did not happen until the 1980s, when mentally ill poor people could no longer afford supportive housing and/or other treatment services. For these mentally ill homeless people, case management, housing, and mental treatment are the most needed services. People who are poor and addicted have high risk of homelessness. Once on the streets, addicts without appropriate treatment lose their chances of getting housing. At least 30% of the single adult homeless population is believed to have addictive disorders. Ending homelessness requires a concerted effort to provide jobs with a living wage, adequate support for those who cannot work, affordable housing, and access to health care. (NCH Fact Sheet #1, 2007). Many mainstream health care services are primarily medical and not organized to deal with the issues that are part of being homeless. Being treated for the "presenting problems" only, without addressing the underlying cause, the person is often discharged back to the environment that contributed to creating the situation in the first place. Given the complexity of problems that face homelessness, it is apparent that no one agency can satisfy all the needs of a homeless person. A fragmented health care system is one of the barriers to providing HCH. Homeless persons face tremendous barriers to treatment services and recovery support, because of lack of health insurance, lack of documentation, waiting lists, scheduling difficulties, daily contact requirements, lack of transportation, ineffective treatment methods, lack of supportive services, fear or distrust of large institutions, and cultural insensitivity. Case management is an answer to overcoming these obstacles. Case management coordinates linkage between and with other organizations, advocates for key services, and provides direct support, in the HCH projects and the community at large, to ensure necessary care for clients who are homeless (McMurray-Avila, 1997). Compared to other health care services, case management addresses the well-being and quality of life of the client as that person defines it, not as defined by diagnostic categories chosen by health care providers. Case management is more than coordinating comprehensive services. It shapes the nature of health care systems so that they become more responsive and relevant. Case managers create continuum of care, in which no barriers in moving between agencies or discontinuities over time in receiving services exist. Case management brings the health care system to a client, rather than asking a client to find it. Moreover, case management can become a source of human support for those who have none. It is not about mastery and control; it is about assistance and advocacy. Case managers are ready to help but not to treat, to care but to not cure, and to maintain rather than to improve (McMurray-Avila, 1997). The case management process includes identifying cases, identifying problems, planning and projecting outcome, implementation, evaluation, and documentation (Utz & Kulbok, 2001). Section II. Case Management Process1) Case finding, screening, and needs assessmentThe first step in case management involves selecting cases by identifying the health needs of clients. The screening process determines the level of care that is needed for each individual. A case is selected when a client has complex needs and is believed to receive the most benefit by the case management service. Target clients who are most likely to need case managers would be those who have frequent hospital admissions, are elderly, have a medical diagnosis that needs elevated attention, are substance abusers, have complex chronic illnesses, are not adherent to medical regimen, or who have suffered major life-changing health events. This step also includes comprehensive and focused assessment of health status and factors affecting health and self-care. Early identification of all relevant problems is important to develop a plan that encompasses care that addresses both the presenting problems and the underlying causes, and prevents future complications and problems (Utz & Kulbok, 2001). Larson (2002) described a screening tool that can be used to measure the health of homeless persons. Short-Form 12-item survey (SF-12), which as derived from the more extended SF-36, was applied to a day shelter and proved to be valuable to assess and monitor health status among homeless persons. The SF-12 survey form contained yes/no questions that assess limitations in role functioning as a result of physical and emotional health, a three-point response scale that assesses limitations in physical activity and physical role functioning, a five-point response scale that assesses pain and overall health, and a six-point scale that assesses mental health, vitality, and social functioning. Out of 145 homeless persons who participated in the survey, 65 % reported to have high blood pressure, 27% asthma/bronchitis/emphysema, 20% arthritis, 17% heart trouble, and 9% sugar diabetes. The results demonstrated that their health needs are great, as evidenced by the high percentage that reported the presence of various symptoms and conditions, in addition to the low physical and mental health scores. 2) Interdisciplinary diagnosis The second step involves a dialogue with a client to determine the strengths and limitations of a client, to identify problems, and to discuss potential approaches to obtain the specific care. This process requires interdisciplinary efforts to incorporate the perspectives of physicians, nurses, therapists, social service experts, the payers, and others. Building a foundation of understanding about what the client agrees about the problem, what the client expects and finds acceptable, would be an important component in this step to make sure the subsequent plans to be complete and useful (Utz & Kulbok, 2001). 3) Planning and outcome projectionThis step is to prioritize objectives based on assessments and, in consensus with the client and the interdisciplinary team, and to devise an individualized care plan with flexible and realistic goals. Projecting outcomes in this step is one of the most important case management processes. For a homeless population, quality of life and ability to function are important outcome parameters. Outcomes can be defined at the individual clinical level (e.g., client's functional level increased in a specific time frame), at the group level (e.g., more people contacted service providers), or at the system level (e.g., decreased hospital admissions). Johnson et. al. (1999) compared different types of case management models that were applied to persons who are homeless and mentally ill. These models have resulted in slightly different outcomes in the different levels. Exploring these models might be a good idea for planners of HCH to decide which model would be appropriate for a specific local situation. The Assertive Community Treatment (ACT) model has been used as an intervention for persons with serious mental illness. The characteristics of this model are assertive treatment in the community, direct sustained support 24 hours a day by the ACT team, assistance with symptom management, and facilitation of supportive social and family environment. At the system level, the ACT has been associated with reduced hospital inpatient days. The Continuous Treatment Team (CTT) model takes continuous, year-long responsibility for providing and soliciting the treatment, rehabilitation, and essential services for a designated number of clients. The Strengths Model features assessment procedures focused on strengths rather than deficits, the training program employed, and a high degree of responsibility given to the client in directing and influencing the intervention. These models had client-to-staff ratios varied between 10:1 to 15:1. There were no significant differences in overall outcomes among ACT, CTT, and Strengths models. All of the models provided outreach, advocacy, medical evaluation, planning, medication maintenance, as well as assistance with housing, entitlements, and budgeting. Other services included counseling, employment assistance, and psychosocial services. A large number of persons in the projects had substance abuse needs as well as mental illness. Also employment and addiction emerged as increasingly important problems to deal with. The process of case management described does not necessarily happen linearly in HCH. Even though early assessment is crucial to define care plans and interventions, even before being able to perform an assessment, a case manager may spend weeks or months or even years engaging the client and building trust. This is especially true with the homeless who are mentally ill or who have been on the streets for many years. To build trust, a case manager might offer a desired service or referral even before knowing the client's full situation (McMurray-Avila, 1997). Whether case managers should provide counseling is an important element to clarify in the case manager's job description from the beginning. Because homeless people often have issues that could best be addressed by therapy or counseling, and because case managers provide support and advice regularly, the case managers may once in a while function as counselors. This should be advised based on the qualifications of the case manager, the availability of other counseling services, and both the case manager's and client's comfort level (McMurray-Avila, 1997). If case management does not include counseling that requires professional training, non-degreed case managers may be employed. It is sometimes helpful to hire former clients as case management assistants or client advocates who can assist their peers with some of the basic case management tasks. They can also function as an informal peer counselor to encourage the homeless individual in overcoming personal difficulties. These "street-savvy" community health workers can be a valuable part of HCH. CHWs are promoted as a mechanism to increase community involvement in health promotion efforts. Swider (2002) reviewed the outcome effectiveness of CHWs. Even though CHWs are believed to increase access to care, especially in underserved populations, she found the only small number of studies that document outcomes in the areas of increased health knowledge, improved health status outcomes, and behavioral changes, with inconclusive results. Dower et. al. (2006), however, paint a brighter picture in utilizing CHWs. They support CHW as a vital missing link that could provide an improved health care system and suggest detailed sustainable financing schemes. They argue that CHWs can be effective and valuable individuals working to improve the health of people and their communities. CHWs may be members of health care teams or may work within communities and autonomously from the health care system. CHWs perform tasks such as - information and referral, education, informal counseling and emotional support, advocacy, and cultural brokerage between providers and recipients. It is with these functions that CHW could be a valuable member of the interdisciplinary health care team, providing case management to homeless clients. Economically, formalization of CHWs into the health care system by sustainable financing could be a source of lifting up the communities of an underserved population, as well as contributing to the health care cost saving. 4) Implementation, service provision, and resource allocation In this step, case managers set up linkages to coordinate, facilitate, and at times provide comprehensive services in conjunction with the plan. A wide array of community resources across the continuum of care must be analyzed with regard to access, affordability, and availability. The dimensions of access include direct factors, such as the client's financial screening, and indirect factors, such as availability of transportation and schedule conflicts. Subjective beliefs and prior experiences of clients, discrimination by race, gender, socioeconomic status, age, or mental status can also indirectly affect access to care. Monitoring the care and the interim outcomes during implementation is another component of the case manager's role, in order to evaluate progress and quality of linkages (Utz & Kulbok, 2001). Resource allocation includes how to get funds for the uninsured or clinics with outreach programs. 5) Evaluation and follow-upIn this step, case managers compare projected outcomes with actual outcomes of care, to determine if or when changes in the plan are necessary. This process is essential to enhance both the quality and cost-effectiveness of the service provided. As the outcomes were projected at the planning stage at the different levels, i.e., individual, group, and system, these outcomes now can be evaluated and scored. For a homeless population, quality of life and ability to function are the most important individual outcome parameters to evaluate. Specific definition of outcomes might be necessary to score the outcome parameters, such as number of sober days or learned skill sets. 6) Documentation Finally, documentation is needed to communicate the plan of care as well as provide a record of events and a legal document. This is necessary to organize individual care and also for system-level reports that would be required to provide the continuum of care. Also, documentation for evaluation, cost-benefit, and outreach efforts would be a valuable record to keep. Section III. Conclusion.Case management model includes many facets of HCH. It navigates and links across and through horizontal and vertical layers of care needs, services, and in between. The difficulties of caring for the homeless is that they require a long time commitment, beyond simple follow-ups, to make sure the pre-defined outcomes have been obtained. Because many homeless individuals significantly lack normal cognitive functions and living skills, it challenges the people and system that have been set up to help them. The seriousness of the situation and state of the homeless population will test the level of dedication and sustainability of the HCH program. ReferencesDower, C., Knox, M., Lindler, V., & O'Neil, E. (2006). Advancing Community Health Worker Practice and Utilization: The Focus on Financing. San Francisco, CA: National Fund for Medical Education. Johnson, M., Samberg, L., Calsyn, R., Blasinsky, M., Landow, W., & Goldman, H. (1999). Case Management Models for Persons Who Are Homeless and Mentally Ill: The ACCESS Demonstration Project. Community Mental Health Journal, 35:4, 325-346. Larson, C. O. (2002). Use of the SF-12 Instrument for Measuring the Health of Homeless Persons. Health Services Research, 37:3, 733-750. McMurray-Avila, M. (1997). Organizing Health Services for Homeless People: A Practical Guide. Nashville, TN: National Health Care for the Homeless Council. NCH Fact Sheet #1. (2007) Why are People Homeless? National Coalition for the Homeless, Retrieved on November 17, 2007 from National Coalition for the Homeless The National Coalition for the Homeless - National Coalition for the Homeless. Swider, S. M. (2002). Outcome Effectiveness of Community Health Workers: An Integrative Literature Review. Public Health Nursing, 19:1, 11-20. Utz, S.W. & Kulbok, P.A. (2001). Case Management: A Nursing Role. In J. Creasia & B. Parker (Eds.), Conceptual Foundations: The Bridge to Professional Nursing Practice (pp. 141-157). St. Louis: Mosby Elsevier.

Difference is one more year of study and either MSN or DNP. (MSN getting 1 year certificate FNP, total 3 years vs. MSN getting FNP through DNP, total 4 years) I don't know why people are so fussy about this. Is there any field that you can get a doctorate for just one more year after master's degree? My concern is different. Compared to second degree PA programs after which you can be FNP-parallel PA-C in just two years, now DNP-FNP will take THREE to FIVE years post the first degree. That includes one year of real RN experience. In real life, who and what will compensate for this extra experience and work compared to PA-C? That is my question. If this lon.....g years of study kicks people away in the gate, it will be a loss to nursing against other health care professions such as PA, PT, etc. Somebody needs to renovate RN workplace so people can stay at jobs HAPPY without having to go upward to NP/APRN to avoid dreaded RN work. Amitai.

Even many RNs in the ER I work do not do 'nurs-ings' as I see it. There are quite a few who only want to be a charge nurse and rarely does direct patient care. ER might be different from other unit but would it be that all the people who hated nursing school ends up being in ER? I think and I hope FNPs do 'nurs-ing' more than 'doctor-ing' compared to what PAs and primary care physicians do. It takes a lot more time and money to be FNPs than PAs. Med school... I'm too old for that and I want to do more with patients than just 10 minute Hx-PE-Dx-Tx. Does any medical school teach a whole-person care? Amitai.

so, rchamp59, congrats! and others who got into all those hard programs and even with cash, i admire you. rchamp59, if you are that old as you say you are, are you single or married? Are you looking for housing near Hopkins? I'm a bit younger than you are!! ;-) maybe a few months and possibly going into Hopkins in June, but still waiting for C'ville admission notice. That's UVa. if you are looking for a housing (and believe me, it is so difficult to find one in Baltimore), let me know how you are doing and we might be able to help each other. so sounds like you skipped the accepted students day last Friday? Amitai.

[...read everything I could get my hands on...even outside my scope of practice, such as interpretation of xrays, etc.. I'd try to second guess what was going to be done on every patient and why. Couple of my friends did the same thing and the trauma chief asked them to stop ordering labs and tests so his residents could learn something, lol! ] Thank you, Zenman, That's exactly what I intend to do and the reason for getting this job before I start nursing school. CTs and X-rays can be accessed from computers now and so cool to look at. Just by standing there and listening to what Docs and nurses say, I learn new stuff almost every day. So, it would help whatever I do, RN or NP. Amitai.

Buttons, I didn't mean to be rude and I don't think that obesity has anything to do with this thread. I wanted to tell the initiator of this thread my experience as an ER tech who is planning to attend direct entry MSN program (2 yr) and another year for NP course and clinicals. I think the human dynamics in any health care setting is what drives the institution and in that sense I wanted to say that my experience with some RNs would be valuable in the future if I work as an NP. (because NP is closely working for/with physicians and RNs.) This path is my second career (1st one was scientist.) I started ER tech job couple of months ago so I am still learning. I had to pick up the heart rate before I did EKG but the pt behaved so normal and I kind of missed the changing signs. This would be a good lesson for a future NP-to-be. I am a foreigner, so, I get treated with prejudice by techs who are 20 years younger than I am. I don't get along with the young folks (the 'in-group') and there is nothing I can do about it. This was the reason that I had hard time showing the EKG. It' not my ER, it's MY problem. I take this whole thing as a character-building experience, not really to prepare for NP program. I believe there would be a place for me when I finish my study and get licensed as an NP. Going beyond my realm of work and life to start something new fresh in my middle age was and is a huge challenge. In conclusion, doing RNs before NP program is good and recommended. I would do it like 10 years if I were a lot younger. If your NP program doesn't require RN experience, go for it. They should know what they are doing and even after you graduate and become a new NP and you are still not confident, then you should get some kind of internship. For all RNs who worked this Thanksgiving, cheers! Amitai.

well, I have to say something, I think it relates to this thread because the RN experience before NP program is influenced by those obese old abusive nurses too. I work 3-12 hr shifts as ER tech and get all kinds of s*** from nasty nurses. It's ok, it's my job to take care of them, doing IVs, monitor pts, when they sit around and gossip. I do plan to attend NP program sometime so I watch the flow as much as I can, from triage to Ax, Lab, Dx, Tx, and to admission or D/C. But until I apply critical thinking and start to do decision-making, I know what I try to learn is limited. I see many things though. And one of the valuable lessons is the networking. There are so many interactions among many levels of care, docs, RNs, techs, CT techs, on-call docs, etc. Learning how these things work would help a lot doing NP duties in the future. It is something that a book or school cannot teach. I had one of those obese abusive RN, gone out to smoke outside, while I was doing EKGs and found pt SVT-ing, a doctor and another RN laughing at my EKG because the lines were swaying like spagettie, took 5 minutes to have another doctor pay attention to the EKG and finally start Tx-ing the pt. Health care is people care. That people include health care providers also. Unless we the providers care ourselves and chasten each other, the whole health care system would go down much faster. Amitai.

jen, if i remember correctly, you are at dePaul? may i ask for the newsgroup info? amitai.

Hi, Helper, I applied to Jan 2006 MENP at DePaul. Got much info from Genn here but still not sure what the attrition rate was for the first year of your class. And how many male students do you have in your class? Are they doing just fine as other students? Thanks. Amitai.

Yes, I quote here a paragraph from http://www.aacn.nche.edu/DNP/pdf/DNP.pdf No wonder the current CNSs are against this whole thing. They would have to go back to school for Doctorate! :-o :-o :-o :-o Concurrently and with input from the Task Force on the Clinical Doctorate, the AACN Task Force on Education & Regulation II developed the Working Paper on the Clinical Nurse Leader Role (AACN, 2003), which subsequently was accepted by the AACN Board in October 2003. The development of this new nurse role, Clinical Nurse Leader (CNL), was in response to growing client care needs and to the changing health care delivery environment. In February 2004, the AACN Board approved the development of new models of nursing practice and nursing education at the master's degree in nursing level that result in a new nursing professional, the CNL (AACN, 2004). The CNL is a generalist, provides care in all health care settings at the point of care, and assumes accountability for client care outcomes by coordinating, delegating, and supervising the care provided by the health care team. The CNL is not an advanced practice nurse*, as defined in this position statement. As the education of the generalist nurse is elevated to the master's degree level, it is reasonable to assume that specialty education and the education of those individuals prepared for the highest level of nursing practice would occur at the practice doctoral level. *Advanced Practice Nurses (APNs) is used here to refer to the four direct care roles: certified nurse midwife (CNM), certified registered nurse anesthetist (CRNA), clinical nurse specialist (CNS), and nurse practitioner(NP). :-o :-o :-o :-o Pt. asks a male nurse with white lab coat "are you a doctor?" He responds, "yes, I am, but I am an NP" Pt. asks again "so, you are really a nurse." he reacts disgustingly this time "yes, but I am a doctor!" Pt. pushes the alarm button and says "you better come here quick, I have a mad man here!" Amitai.

Genn, Thank you again for responding to my old question. Regarding the 'resistance' from old timers to CNL role of Master's Entry RNs, I found this http://www.nacns.org/positionstatement.pdf So, within the Nursing community itself, there is a division, probably caused by power conflict as well as money stuff. Some of them do ignore the level of education PAs are getting in two year program after which they get Master's. They all work with(for) physicians after they get license and work fine as a leader. This is to balance the education/profession of Nursing with other health care providers, I think. Old people just don't know how fast today's young people are absorbing materials and applying them. With good mentorship (possibly from CNS staff???), CNL could be educated in two years (not less) to meet the demand of health care. If Nursing cann't do this, the whole Nursing profession will be behind other health care providers. (I feel like I am talking to myself.) Amitai.