I want to thank Phyllis Rocco, Chief Nurse & Dr. Susan Little,

Interim Chief Nurse & Chair of the NCPHA PHN Section for

inviting me to spend time with you all today. And thank Dr.

Shawn Kneipp, the APHA PHN Chair-Elect, much of what you

will hear is a direct result of our work together advocating for

the public’s health and elevating the work of public health

nurses. *Lastly I want to recognize Jaimee Lee Watts, APHA

PHN Section Student Liaison.

Aim for the participants assist each other in seeing their work in a different way & just maybe have a 'bigger' impact on their community's health by working more upstream.  

Be Visible, Vocal, and Valued: How We Can Impact Population

Health Upstream

[SLIDES 1-3]

[SLIDE 4] Before we start our conversation about how we

impact population health upstream, I want to congratulations

the North Carolina Public Health Nurses on 100 years of service

to the public for the public’s good under the direction of the

Office of the Chief Nurse! What an exciting time to reflect on

your history, and all you have accomplished. As many of you

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know your celebration precedes the ‘Year of the Nurse’ in 2020.

Congratulations!

[SLIDE 5] Well, The tea kettle is on full steam as public health

nurses and professionals in North Carolina and across the

nation are busy planning, implementing & evaluating

programs, and responding to complex social and economic

condition such as the opioid epidemic, vaping and the outbreak

of lung related injury, gun violence – mass shootings, public

health emergency preparedness and after disaster recovery,

structural racism, high infant and maternal mortality rates in

African Americans, high threat pathogens, refugee health,

ineffectual laws and policies, climate change and health, air and

water pollution, vaccine hesitancy and vaccine refusal, an aging

water and sewer infrastructure, and the underlying causes of

the social determinants of health. In addition, in 2018, 1.2

million North Carolinians could not find affordable housing and

astoundingly 1 in 28 children under the age of 6 were

homeless. To compound housing instability, one in 5 children

were living in a food insecure home. 47% of women reported

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having experienced intimate partner violence and a quarter of

North Carolina’s children have experienced Adverse Childhood

Events.

To impact population health and address these and other

complex issues public health nurses and professionals must be

visible, vocal, and as a result valued. This requires being

strategic and having the necessary knowledge and skill set to

work across systems, forecast sustain programs that address

complex issues, communicate effectively, advocate, utilize

members of the public health to their full capabilities, and

practice community engagement.

Effectively conveying key concepts and complex issues to the

public, stakeholders, and elected officials is integral to the work

we do. More importantly is it necessary in order to work more

upstream where we can influence and implement policy,

systems and environmental strategies that create healthy

communities and have the greatest impact on population

health. Unfortunately confusion exists across sectors and

disciplines when using key concepts that collectively impact

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population health, those concepts are social needs, social

determinants of health, population health management, and

population health.

As an example the American Public Health Association Public

Health Nursing Section has been actively engaged in providing

information, testimony, and selected readings to the National

Academy of Science, Engineering, and Medicine with the aim to

influence the their Future of Nursing 2020-2030 Consensus

Study and the final report [SLIDE 6] (2019). Our concerns were

heightened with the content of the paper released entitled

Activating Nursing to Address Unmet Needs in the 21st Century

by Patricia Pittman that will serve as the primary background

for the committee’s work. The paper provided background on

the domains and settings in which nurses work but sparsely

mention of the field of public health generally, and public

health nursing, more specifically. The focus of the study is on

the capacity of the nursing profession to meet the anticipated

health and social care demands. As you know social care

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demands or social needs are primarily located in acute and

primary care settings.

[SLIDES 7-9] Twitter screen shots FON2020-2030

And although the report is in development, the focus, unless

there is a drastic change, largely centers on social needs and

population health management, which although important are

not sufficient to improve population health and address

structural barriers that affect social determinants of health.

[OPEN MIC] What are your thoughts about the content and or

direction of the FON2020-2030 study and the implications for

the health of our nation?

How can we influence the direction of this work or the work of

partners to collectively swim in the same direction and move

more upstream?

First it is important to think about how we share community

narratives – the lived experiences of those we serve - threaded

with data, outcomes, and upstream strategies to impact

population health?

5

[OPEN MIC] What are your experiences with traditional

partners or members of the healthcare system and how they

explain their work with social determinants of health?

[SLIDE 10-11] I want to call your attention to Dr. Castrucci and

Auerbach’s important work that distinguishes between social

needs and SDOH and how social needs are necessary but not

sufficient (Castrucci & Auerbach, 2019, January 19). And

suggest that if you have not read the short article you do so and

share it with your traditional partners in the healthcare sector.

We know the meaning of social determinants of health and

population health in the context of community stories and the

work of public health nurses and professionals engage in is

different than the stories those in healthcare share about the

work around social determinants of health & population health

when in actuality they are engaged in population health

management. As Dr. Castrucci suggests the healthcare sector is

redefining social determinants of health to be mostly or only

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about the immediate social needs of high utilizers of the

healthcare system makes it harder to focus on systematic

changes necessary to address the root causes of poor health.

To put it bluntly those in the healthcare sector, although well-

meaning, are co-opting terms that may impede necessary work

upstream by giving the impression short-term results at the

individual level improve population health.

Therefore we must effectively & accurately communicate the

terminology that includes the work of public health in

addressing those conditions that impact the overall health of

the community.

Why do you think public health nurses & professional are

seemingly invisible? And how can we increase our visibility?

[SLIDE 12] Being vocal can raise the visibility of public health

nurses & professionals that daily are silently doing their jobs at

the local, state, tribal, and national levels. Specifically, the

actions that public health nurses take to safeguard the health

of a community may take many different forms. Much of what

we think about when we use the metaphor of a “safety net” 7

includes Public Health Nurses (PHNs) providing health care

services to individuals who might otherwise not be able to

access care in the U.S. healthcare system. This is one crucial

aspect that characterizes the role Public Health Nurses play in

safeguarding a community’s health, but it is not this role that

makes the contributions of nurses working from a public health

perspective unique. As trusted members in the community, we

also engage in safeguarding health through health promotion

and disease prevention activities, public health emergency

preparedness, community health needs assessments and

improvement planning, and policy development and advocacy

that go primarily unrecognized until a crisis arises. Population

health interventions that address the social determinants and

health equity (a more upstream approach) can enhance our

ability to provide safeguards for health while reducing our

reliance on the need for safety “nets” at all.

Moreover, public health nurses are positioned and prepared to

take on expanded roles and leadership to create healthy

communities and impact population health.

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As anchors [SLIDE 13] we must be visible to the communities

we you serve, they must know we exists. And in order to for

that to occur we must be vocal. How many of you enjoy being

interviewed by media outlets? Or public speaking? I know how

you feel but we must develop the necessary skills to elevate the

work we do every day to create healthy communities. But what

if the community does not know there is a public health

department when one actually exists? To illustrate a clear case

of ‘invisibility’ and the importance of strategic communication

and public health nursing leadership, I will share how together

we got a public health department on the map! Strategic

planning, developing a user friendly website, building

relationships with the local media, transferring and sharing the

responsibility of public information officer, and opening the

doors wide to the public and getting out into the community.

Once we successfully opened our doors, established trust with

the community, built capacity of our team we engaged in more

upstream strategies to improve the health of our community.

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Upstream measures, namely advocacy and policy are needed to

address social and structural determinants of health. Examples

of upstream measures include: lending practices, impact of

affordable housing stock [SLIDE 14], rent policies, home

inspection policies, availability of public transportation [SLIDE

15], access to legal aid, payday lending [SLIDE 16] ,

food/nutrition policies such as SNAP or WIC [SLIDE 17], access

to preventive services, family planning through Title X funding,

maternal child services, co-located services, and blending public

and private funding, but are these upstream measures are

often lacking. [SLIDE 18] Public health nurses are instrumental

in monitoring and assessing health trends for planning &

forecasting, analyzing existing policies, developing and

proposing policies, and educating the public and elected

officials through advocacy.

[OPEN MIC] [SLIDE 19] Now thinking about where and how

you practice; what would it take for you to move further

upstream? (Castrucci, Fielding, & Auerbach, 2019, September

4)

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[OPEN MIC] What are your experiences with traditional

partners or members of the healthcare system and how they

explain population health strategies they engage in?

I will share a case example that that ties together all the key

concepts we have discussed and working more upstream. The

case contextualizes social determinants of health, social needs,

population health, and population health management and

public health nurses working midstream and upstream. The

county I served as public health department director, had a

hospitalization rate, for adult residents, 50% higher than the

state rate for COPD, which in adults is a potentially preventable

hospitalization (PPH) condition.1 The public health department

collaborated with community stakeholders to implement

evidence-based interventions through community coordination

to address the high COPD rates and the associated healthcare

costs. Stratifying data by race/ethnicity & zip codes, persons of

color in one of the four zip codes were found to be

disproportionally affected.

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Public Health Nurses educated the public, elected officials, and

advocated for a Smoke-Free Ordinance that voters ultimately

passed [SLIDE 20]. The ordinance is an upstream primary

prevention strategy to reduce risk of exposure for the entire

population and improve population health by changing social

norms and behavior. Healthcare stakeholders engaged in

population health management in the acute care setting by

identifying the social needs of adult patients diagnosed with

COPD. Based on identified social needs, the public health

department secured funding to launch middle stream strategies

that included linking patients, pre-discharge, to free smoking

cessation classes that included no-cost nicotine replacement

and provided free Pneumovax and flu vaccines. The smoking

cessation classes were held in a central location on the transit

route. To further address social determinants of health, the

health department worked with city transportation to evaluate

route use and community need by zip code and new routes

were approved for two disproportionally affected zip codes.

These efforts decreased hospitalizations by 10.5%, hospital

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charges by 2.3%2 and adults reporting smoking from 26% to

14%. This multi-pronged coordinated approached lead by Public

Health Nurses achieved efficient and effective population

health management and improved population health.

[OPEN MIC] Now thinking about the case, how would you

sustain the efforts of the health department? What would

you need to know in order to forecast sustainability?

[SLIDE 21 AFTER THE OPEN MIC – Make sure covered by

audience]

Fig. 2 Sustainability theory of change conceptual model (p. 4)

(Vitale et al., 2018)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6158899/13

[SLIDE 22] What about funding? Public health funding whether

it is pass through state funding, city or county funding, or grant

funding always poses a challenge to the health of communities.

The funding portfolio for health which is largely public health

and medical care is grossly imbalanced. Public health funding

accounts for only 2.5% of U.S. 3.5 Trillion (17.9% of the GDP) in

healthcare dollars in 2017 (Centers for Medicare & Medicaid

Services [CMS], 2018). We know that about 5% of the US

population is responsible for approximately 50% of medical

care spending. In addition many in public health partner with

the healthcare sector on community benefit projects. In a 2015

report from the IRS to Congress, the IRS indicated that: 92% of

the $62.4 billion spent in 2011 on Community Benefit

supported activities related to clinical care—charity care,

payment shortfall from Medicaid or similar programs, and

graduate medical education—as well as research (Rosenbaum,

Kindig, Bao, Byrnes, & O’Laughlin, 2015). Approximately 7%

was divided between community health improvement and

contributions to community groups (Rosenbaum et al., 2015).

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Grants are taking the place of stable funding and as many of

you know when funders like the state health department

deems a grant funded program or initiative successful, funding

stops and is shifted to the next hot issue instead of continuing

the funding to sustain the effort. Or more importantly funding

the program in news ways to build community capacity to

sustain the effort. The decrease in public health funding and

the positions many public health nurses fill are limiting public

health nursing’s capacity to engage in upstream measures to

address structural issues that impact social determinants of

health and subsequently, population health.

One strategy those in public health leadership positions can

employ is to maximize and thus challenge public health nurses

by ensuring they are practicing in ‘unexpected ways and in

different places’ within the organization and in the community

to improve population health upstream [SLIDE 23].

Opportunities exist for PHNs to be at the forefront of the

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planning and implementation of programs, to proactively seize

opportunities to engage in primary prevention and

collaboration and partnership with community providers and

organizations, be a formal liaison between community & the

healthcare system, bridge the gap between clinical delivery of

care and community/population level prevention services.

However, to engage in advocacy and policy development and

work in unexpected ways some public health nurses may need

training & mentoring to build self-efficacy.

Many years ago I visited the prison where Nelson Mandela

spent 27 years and was struck by the motto he and his fellow

prisoners embraced – “Each One Teach One.” [SLIDE 24] In

order to build skills, which is what Mr. Mandela and the other

prisoners did, mentorship is required. Using the QCC C/PHN

Competencies [SLIDE 25] as a guide to developing a

competency based practice coupled with mentorship and

coaching are strategies that can assist PHNs in finding their

Advocacy Voice and move upstream! And as a result I believe

PHNs will find and embrace their power to transform

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communities. Transforming communities necessitates that

PHNs work differently and in non-clinical domains that have the

greatest upstream impact. And it requires leadership to think

differently about how PHNs are being utilized to lead upstream

efforts. [SLIDE 26]

In closing to impact population health together we must

advocate for upstream strategies that dismantle structural

barriers that are the root cause of social determinants of

health. The communities we serve need more policies and

program, less pills and procedures to impact population health,

and public health nurses to lead the work.

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References

All-Party Parliamentary Group on Global Health. (2016, October ). Triple Impact – how developing nursing will improve health, promote gender equality and support economic growth. Retrieved from https://www.who.int/hrh/com-heeg/digital-APPG_triple-impact.pdf

American Hospital Association [AHA]. (2012). Managing Population Health the Role of the Hospital. Retrieved from https://www.aha.org/system/files/hpoe/Reports-HPOE/managing_population_health.pdf

Beck, A. J., & Boulton, M. L. (2016, January-Feburary). The public health nurse workforce in U.S. state and local health departments, 2012. Public Health Reports, 131, 145-152.

Castrucci, B. C., Fielding, J., & Auerbach, J. (2019, September 4). Social determinants of health — health care isn't just bugs and bacteria. Retrieved from https://thehill.com/opinion/healthcare/459849-social-determinants-of-health-health-care-isnt-just-bugs-and-bacteria

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Rosenbaum, S., Kindig, D. A., Bao, J., Byrnes, M. K., & O’Laughlin, C. (2015). The value of the nonprofit hospital tax exemption was $24.6 billion in 2011. Health Affairs, 34(7), 1225-1233.

Rozier, M., Goold, S., & Singh, S. (2019). How Should Nonprofit Hospitals’ Community Benefit Be More Responsive to Health Disparities? AMA J Ethics, 21(3), E273-280. doi:10.1001/amajethics.2019.273

World Health Organization [WHO]. (2019, January). Executive Board designates 2020 as the “Year of the Nurse and Midwife”. Retrieved from https://www.who.int/hrh/news/2019/2020year-of-nurses/en/

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Castrucci, B. C., & Auerbach, J. (2019, January 19). Meeting individual social needs falls short of addressing social determinants of health [Health Affairs Blog]. Retrieved from https://www.healthaffairs.org/do/10.1377/hblog20190115.234942/full/

Castrucci, B. C., Fielding, J., & Auerbach, J. (2019, September 4). Social determinants of health — health care isn't just bugs and bacteria. Retrieved from https://thehill.com/opinion/healthcare/459849-social-determinants-of-health-health-care-isnt-just-bugs-and-bacteria

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