20090817 NFUNLEC Vulnerable Population

Dr Aubrey Go on Vulnerable Population (notes in-class) 2 hr Nursing 205 Fundamentals Lecture 1300-1500 Monday August 17th 2009 Vulnerable Population and Vulnerability vs. Risk socioeconomic problems risk – based on the natural history of disease model – difficult to maintain a job – antipsychotic medications physiology and environment – counseling personal habits, social environment physical environment – group therapy Vulnerable Population – vocational assistance • a subgroup of the population more likely to develop health Substance Abusers problems as a result of exposure to risk or to have worse outcomes • legal substances from these health problems than the population as a whole • illegal substances • cumulative risks make them more sensitive to the adverse health problems effects of individual risk factors and • Vulnerability implies that certain people are more sensitive to socioeconomic problems risk factors than others – heart problems Vulnerable Population Groups – liver CA 1. Poor and Homeless Persons – HIV 2. Pregnant Adolescents – crime 3. Migrant Workers – communicable diseases 4. Severely Mentally Ill Individuals – family breakdown 5. Substance Abusers 6. Abused Individuals Abused Individuals 7. People with Communicable Diseases and Those at Risk • physical 8. HIV, Hepatitis and STDs • emotional • sexual Poor People • neglect • hazardous environments • high-risk jobs • eat less-nutritious diets • multiple stressors • no extra resources • no adequate resources to manage daily life Homeless • fewer resources than poor people • must struggle with even more demands as they try to manage daily life • do not have the advantage of shelter • find a place to sleep, to stay, food to eat before thinking about health care • PROBLEMS: • foot problems • dental problems • hypothermia • exacerbations of chronic health problems • violence • trauma Pregnant Adolescents • adolescent mother, infant, future children • lower socioeconomic status • interrupted education for one or both parents • limited job opportunities • additional expenses associated with childrearing • long-term cycle of economic problems • PROBLEMS: • low-birth-weight infants • toxemia • pregnancy-induced hypertension • anemia Migrant Workers • occupational risks – hazardous work – poor working conditions • socioeconomic risks from poverty and homelessness • crowded living conditions • traveling to work in crowded buses • malnutrition • episodically homeless/ hidden homeless

domestic violence – a pattern of regularly occurring abuse and violence, or the threat of violence, in an intimate relationship • child abuse – 2.9M (1992) – neglect, physical, sexual – 1994, rising faster – posttraumatic symptoms – emotional problems – addictive behaviors – dysfunctional families – financial strain People with Communicable Diseases and Those at Risk • immunization status • drug resistance of bacteria – measles outbreak – drug-resistant S. aureus – tuberculosis (TB) – HIV, AIDS, CA, very young, very old HIV, Hepatitis, STDs • infectious diseases – TB – Pneumocystis carinii pneumonia • CA – Kaposi’s sarcoma •

– herpes simplex virus 2 ◊ cervical CA socioeconomic problems – work, family, life-style disruptions – loss of insurance – social, psychological, emotional problems

Trends in Health Care

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colonial times ◊ chronic physical or mental conditions were cared for in the community

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19th century ◊ institutional care

latter part of 20th century ◊ renewed emphasis on care • more outreach and case finding to make access easier and more culturally competent • more comprehensive, family-centered services • more accessible – school, church, neighborhood, workplace Public Policies Affecting Vulnerable Populations • Legislation that Provided Direct and Indirect Financial Subsidies to Certain Vulnerable Groups

Migrant Workers • PROBLEMS: – access to health care • illegal immigrants may have no legal access to health services, depending on the laws in a particular state

– Social Security Act of 1935 – Medicare and Medicaid Amendments of 1965

Social

Security

Act

Public Policies • Social Security Act of 1935 – largest federal support program for elderly and poor

Severely Mentally Ill • major psychosis: schizophrenia, bipolar disorder health problems 1 of 3

Dr Aubrey Go on Vulnerable Population (notes in-class) 2 hr Nursing 205 Fundamentals Lecture 1300-1500 Monday August 17th 2009 – ensure a minimal level of support for people who – 1 out of 8 Americans lives in a family with an income had a level of vulnerability to problems resulting from below the Federal poverty level (Healthy People 2000) inadequate financial resources – Federal Poverty level (family of 4) - $22,050 (2009) – direct payment to eligible individuals • Medicare and Medicaid Social Security Act Amendments of *medically indigent – people who do not have the financial resources to 1965 pay for medical care – provide for the health care needs of elderly, poor • health care reimbursement policies and disabled – market model vs. human service model – created third-party payers at the federal and state • people who have the resources to purchase levels who provided financial assistance by paying for services are the ones entitled to those services health services – Social Darwinism vs. health as a basic right • Legislation that Provided Financial Support for Building Health Care Facilities *groups who are unable to afford adequate preventive services are likely to – Hill-Burton Act of 1946 develop chronic diseases ◊ drain on human capital – Community Mental Health Centers Act of 1963 Predisposing Factors – Stewart B. McKinney Homeless Assistance Act of 2. Age-related Causes 1988 – extreme ages • Hill-Burton Act of 1946 – prone to infections and communicable diseases – provided financial support to build hospitals that – less effective immune system would provide care to indigent people 3. Health-related Causes – alteration in normal physiologic status predisposes • Community Mental Health Centers Act of 1963 individuals to vulnerability – construct community mental health centers – HIV, hepatitis, STDs – train mental health professionals who would provide – physiologic alterations ◊ accidents, injuries, congenital community-based care for the severely mentally ill problems ◊ mental or physiological disability individuals who were discharged from state mental 4. Life Experiences hospitals – childhood experiences influence the development of psychological vulnerability or resilience

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disaster ◊ counseling 1. events are outside their control – extroversion and flexibility – protective factors against early adversity Outcomes of Vulnerability • negative – lower health status

McKinney Homeless Assistance Act of 1988 – clinics – educational services – social services for homeless individuals and families • Legislation that Affected How Health Care Resources were Used – National Health Planning and Resources Development Act of 1974 – Tax Equity and Fiscal Responsibility Act of 1982 Public Policies • National Health Planning and Resource Development Act of 1974 – intended to provide local mechanisms for planning which types of health services and facilities were really needed – duplication of expensive facilities and services would be avoided – Goal: reduce the increasing cost of health services – community health needs assessment provide balanced services so all would have access to the care they needed • Tax Equity and Fiscal Responsibility Act of 1982 – designed to limit the rapid increase in health care costs – did not focus on community planning – mandated that payment for hospital services for all Medicare patients would no longer be done in a retrospective cost basis – Health Care Financing Administration (HCFA) would no longer simply pay bills that were submitted to them for Medicare enrollees – a list of diagnosis-related groups was developed and determining what they would pay for caring for people with these diagnoses – emphasis on shorter hospital stays, cost-effective treatments, community-based care and care in the home Implementation Issues Health Risk • multiple cumulative risks • sensitive to the effects of the risks – environment (lead exposure) – social (crime and violence) – biological or genetic make-up (congenital addiction or compromised immune status) • co-morbidities/multiple illnesses Predisposing Factors 1. Socioeconomic Status – poverty •

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positive – with effective interventions ◊ improved health and empowerment • Poor Health Outcome • worse health outcomes than others in terms of morbidity and mortality • high prevalence of chronic illnesses • high levels of communicable diseases • high mortality rates from crime and violence 2. Chronic Stress – manage health problems with inadequate resources

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domino effect ◊ hopelessness

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Hopelessness – results from an overwhelming sense of powerlessness and social isolation Cycle of Vulnerability predisposing factors + outcomes of vulnerability = a cycle in which the outcomes reinforce the predisposing factors ◊ more negative outcome

break the cycle NURSING • Nursing Process – assessment – vulnerable individuals, families, groups and communities – nursing diagnoses – strengths and needs – planning appropriate therapeutic – intervention nursing interventions – evaluation – effectiveness of interventions Assessment Issues • Socioeconomic Considerations – assess client’s perceptions of his or her socioeconomic resources – identify people who can provide support and financial resources – support: information, caregiving, emotional support, transportation, shopping, babysitting – financial resources: health services and medications, eligibility for third-party payment – ask about the perceived adequacy of both formal and informal support networks 2 of 3

Dr Aubrey Go on Vulnerable Population (notes in-class) 2 hr Nursing 205 Fundamentals Lecture 1300-1500 Monday August 17th 2009 Physical Health Issues – preventive health needs – screening tests – immunization status, blood pressure, weight, serum cholesterol, Pap smears, breast exams, mammograms, prostate exam, glaucoma screening, dental evaluation – preventive screening for diseases that they are high risk • Biological Issues – congenital and genetic predisposition – education – counseling – referral to other health professionals • Psychological Issues – stress levels – healthy or dysfunctional family dynamics – stressors – coping styles – levels of self-efficacy – overall sense of well-being – level of self-esteem – depression – anxiety • Lifestyle Issues – dietary patterns – exercise – rest – use of drugs, alcohol, caffeine – cultural preferences • Environmental Issues – exposure to environmental hazards – living environment – neighborhood surroundings – pollution, industrial wastes, crime * nurses should establish partnerships •

Nursing Roles (CHN) When Working with the Vulnerable • case finder • health teacher • counselor • direct care provider • monitor and evaluator of care • case manager • advocate • health program planner • participant in developing health policies Case Management • involves linking client with services and providing direct nursing services, such as teaching, counseling, screening, and immunizing • brokering health services is accomplished by making appropriate referrals and by following up with clients to ensure that the desired outcomes from the referral were achieved Levels of Prevention • Primary – prophylaxis – vaccination • Secondary – health screenings • Tertiary – therapy group – enhance level of self-esteem Evaluation of Nursing Interventions with Vulnerable Population • extent to which client health outcomes were achieved (goals and objectives) • basis for revision to make it more effective • case closed or program is completed – gives nurses data to use in the future • incidence data, prevalence data, survey data, service utilization data – used to evaluate health programs for vulnerable populations

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