Nurses stand at the forefront of healthcare, uniquely positioned to address health equity and dismantle systemic barriers that prevent individuals from achieving optimal well-being. Understanding “How Does The Nurse Implement A Health Care Program” is crucial in today’s landscape, where health disparities are starkly illuminated by events like the COVID-19 pandemic and ongoing social crises. Nurses are not merely caregivers; they are architects of health programs, advocates for social justice, and vital connectors within communities. This article delves into the multifaceted ways nurses implement health care programs, focusing on their pivotal role in advancing health equity across clinical settings, communities, and policy landscapes.
Understanding the Nurse’s Role in Health Equity Initiatives
The nursing profession’s foundation is deeply rooted in social justice and community health advocacy. Historically, nurses have been champions for the underserved, recognizing the profound impact of social conditions on health outcomes. This legacy is reinforced by the Code of Ethics for Nurses, which compels nurses to actively challenge racism, discrimination, and injustice. Achieving health equity, where everyone has a fair opportunity to be as healthy as possible, necessitates a comprehensive approach that goes beyond traditional healthcare delivery. Nurses are central to this approach, addressing the underlying causes of poor health by acknowledging the wide array of factors influencing health, developing targeted solutions, and collaborating across disciplines and sectors.
To effectively integrate social care into healthcare, nurses operate within five complementary areas: awareness, adjustment, assistance, alignment, and advocacy. For instance, in awareness, a hospital nurse identifies post-discharge fall risks and leverages patient assets to improve health. In adjustment, telehealth or home health nurses modify clinical care to mitigate fall risks in the home environment. This extends to advocacy, where nurses champion health policies to reshape community infrastructure and prevent falls on a larger scale. Improving population health fundamentally requires challenging and transforming the societal factors and institutions that perpetuate health inequity. Nurses are instrumental in driving these interventions and reforms, targeting institutions, social systems, and public policies to foster a more equitable health landscape.
Figure 5-1
Alt Text: Diagram illustrating five interconnected areas of activity for strengthening social care integration into healthcare: Awareness, Adjustment, Assistance, Alignment, and Advocacy, each contributing to a more holistic and equitable healthcare system.
TABLE 5-1
Alt Text: Table defining the five areas of activity for integrating social care into healthcare: Awareness (identifying social needs), Adjustment (tailoring care), Assistance (direct aid), Alignment (coordinating services), and Advocacy (policy change), emphasizing a multi-faceted approach.
Implementing Health Programs in Clinical Settings: Addressing Social Needs
While clinical care is considered a downstream determinant of health, clinical settings offer crucial opportunities for nurses to address midstream determinants – social needs. Screening for social needs and connecting patients with social services are increasingly vital components of holistic care. Nurses are uniquely positioned to conduct these screenings, review results, formulate care plans addressing identified social needs, refer patients to relevant professionals and services, and coordinate care with social workers and community health workers. Despite the growing recognition of social needs screening, it is not yet universally implemented. Many practices and hospitals do not consistently screen for key social needs domains: food insecurity, housing instability, utility needs, transportation challenges, and interpersonal violence. Nurses, as trusted healthcare professionals who spend significant time with patients, are ideally suited to bridge this gap. Federally Qualified Health Centers (FQHCs) often exemplify best practices by routinely screening for social needs.
However, challenges persist in clinical social needs screening. Patients may be reluctant to disclose sensitive information about housing or food insecurity. Furthermore, effective data collection and sharing technologies are needed to integrate social needs data into nursing practice meaningfully. While nursing education builds foundational skills for assessing both health and social needs, policy support within healthcare organizations is crucial to prioritize this expanded role. As social needs integration becomes more prevalent, nursing education must emphasize the profound impact of social needs and social determinants of health on individual and population well-being. Effective communication training is also essential to ensure patients feel comfortable answering personal questions about housing, violence, or financial insecurity. Ultimately, the value of social needs screening hinges on robust networks of community agencies providing accessible services and resources. Healthcare organizations must dedicate resources to connect patients with appropriate services, track referrals, and offer ongoing support to ensure screenings translate into tangible improvements in patients’ lives.
BOX 5-1
Alt Text: Icon indicating a boxed section of text, representing supplementary information or a case study related to the main article content.
Community-Based Health Programs: Tackling Social Needs and SDOH
Nurses have a long-standing history of addressing social needs and social determinants of health (SDOH) within community settings. Community-based nurses often directly address social needs at the individual and family levels while simultaneously tackling broader SDOH at the community and population levels. Public health nurses, in particular, possess extensive knowledge of community health issues, SDOH, available resources, and unmet needs. Their embedded position within communities fosters trust and respect among community leaders. Home visiting nurses also play a critical role, often serving as the first point of sustained healthcare engagement for individuals facing social challenges. They identify and address social needs limitations, such as transportation barriers, and collaborate with interdisciplinary teams, like those at WIC clinics, to address food insecurity and other pressing social needs. By engaging directly in neighborhoods and homes, public health and community nurses promote family and community well-being, collaborating with partners across social, health, and other service sectors.
At the population health level, public health nurses are instrumental in achieving health equity through health promotion, disease prevention, and control initiatives. Often employed by municipal and state health departments, they apply nursing, social, epidemiological, and public health sciences to improve population health. Their services span policy development and coalition building to health education and case management. Public health nurses serve diverse populations, including those with complex health and social needs, the elderly, homeless individuals, teenage mothers, and those at risk for specific diseases. Their interventions target health risks like substance use disorder, HIV, and tobacco use, or focus on at-risk populations. Key skills they bring to communities include assessing individual, family, and community health needs; utilizing data and environmental knowledge to address public health issues; contributing to policy and program development; implementing evidence-based programs; and managing program budgets.
Collaboration and community partnerships are central to public health nursing roles in addressing SDOH. Core activities include community organizing, coalition building, policy analysis, engagement in local government meetings, collaboration with state health departments, and social marketing. Despite their foundational work, public health nurses often remain unseen, and research directly linking their roles to measurable reductions in health disparities is limited. Recent public health crises, including H1N1, Ebola, Zika, and COVID-19, underscore the critical need for robust, well-connected, and well-resourced social services, public health infrastructure, and healthcare systems, all supported by a sufficient number of well-educated nurses. Public health nurses, as trusted professionals with broad community presence, are vital for disseminating accurate health information during outbreaks and emergencies, serving as expert sources and extending the reach of crucial messaging.
Fostering Interdisciplinary and Multisectoral Programs for Holistic Needs
Nurses are increasingly implementing health care programs through collaborative efforts across disciplines and sectors. These partnerships create interventions that address the complex, multifaceted needs of individuals and communities, leading to far-reaching improvements in health outcomes and healthcare utilization. By partnering, community-based nurses can tackle a wide range of health-related needs, from population-level diabetes management to community transportation solutions that improve healthcare access for low-income families.
Given the multitude of factors influencing health, a multidisciplinary, multisectoral approach is essential to effectively improve health and reduce health inequity. While single-focus interventions might address one aspect of health, such as food insecurity, intersectional approaches that simultaneously address the holistic needs of individuals, families, and communities are often necessary. Under-resourced communities frequently face intersecting challenges, from environmental hazards to food deserts. Healthcare systems, community organizations, government entities, nurses, and other stakeholders are increasingly collaborating to design interventions that reflect this complexity. Creative alliances are emerging between for-profit and non-profit organizations, community groups, federal programs, hospitals, lending institutions, and technology companies.
Community health needs assessments (CHNAs) are a vital opportunity to inform multisectoral efforts to prioritize and address health disparities. The Affordable Care Act mandates non-profit hospitals to conduct CHNAs every three years, incorporating input from local public health agencies. These assessments identify and prioritize significant community health needs, resources, and action plans. The CHNA process itself is a multisectoral collaboration, requiring engagement with community stakeholders. CHNA results create opportunities for cross-sector partnerships. For example, a hospital might collaborate with public health and food banks to combat food insecurity, or partner with tech companies and school boards to enhance digital literacy and broadband access for telehealth in underserved youth and families. Hospitals are required to consider community input in these assessments, including expertise from public health professionals and organizations, and to make the resulting reports publicly available. Nurses from diverse clinical and community settings can be involved in all stages of CHNAs, from design to implementation and evaluation. The Magnet recognition program even requires participating hospitals to include nurses in their CHNAs.
Various models showcase nurses directly addressing health and social needs through multidisciplinary, multisectoral collaboration. Two notable examples are the Camden Core Model and the Edge Runner initiative.
Camden Core Model
The Camden Coalition in New Jersey exemplifies a multidisciplinary approach, working across sectors to address complex health and social needs. Recognizing the healthcare system’s frequent failures for individuals with complex needs, the Coalition utilizes diverse strategies, including faith-based partnerships, data sharing across sectors (criminal justice, healthcare, housing), and coalition building. Their Camden Core Model is a nationally recognized, nurse-led care management intervention for individuals with complex medical and social challenges. Applying trauma-informed care and harm reduction principles, it empowers individuals to gain the skills and support needed to reduce preventable hospital use and improve their well-being. The model uses real-time hospital admission data to identify “superutilizers” – individuals with complex issues who frequently use emergency care. An interprofessional team of registered nurses (RNs), licensed practical nurses (LPNs), social workers, and community health workers engages directly with these individuals to navigate care, connecting them with medical services, government benefits, and social services. This model has been replicated in other cities with federal funding.
Camden Coalition partnerships optimize nurses’ community role through interprofessional teams visiting participants, reconciling medications, accompanying them to appointments, and linking them to social and legal services. Recruiting nurses from the local community is crucial, leveraging their cultural and systems knowledge to improve access to services. The Coalition’s culture, with a unified commitment to addressing complex needs, fosters a supportive environment where each team member’s role is maximized. Care team members assist with primary care appointments, public benefit applications, referrals, medication delivery, and care coordination. The Camden Coalition emphasizes “authentic healing relationships” built on secure, genuine, and continuous partnerships between care team members and patients. This led to the COACH framework for patient engagement: Connect tasks with vision, Observe routine, Adopt coaching style, Create backward plan, and Highlight progress. Teams problem-solve with patients to manage chronic conditions and reduce preventable hospital admissions.
Initial evidence indicated significant reductions in hospital charges and visits, and increased provider reimbursement. However, a later randomized controlled trial (RCT) found the Camden Core Model did not reduce hospital readmissions. Conversely, RCTs in Philadelphia and Chicago demonstrated that similar social care programs with case management and community health workers can reduce hospital admissions, save costs, and improve health and care quality. The Philadelphia IMPaCT program, using community health workers, showed improved care quality and reduced hospital days, saving $2.47 for every Medicaid dollar invested annually. The Chicago RCT found a case management and housing program reduced hospitalizations by 29% and emergency department visits by 24% for homeless adults with chronic conditions.
Edge Runner
The American Academy of Nurses’ Edge Runner initiative highlights and promotes nurse-designed care models and interventions that enhance health, access, quality, and cost-effectiveness. As of February 2020, 59 programs had been recognized. Many Edge Runner programs prioritize underserved communities and aim to improve health through holistic care addressing social needs and SDOH across upstream, midstream, and downstream determinants. An analysis of 30 Edge Runner models identified four common themes illustrating their comprehensive approach to health:
Holistic Definition of Health: Programs broadly define health encompassing physical, psychological, social, spiritual, functional, quality-of-life, happiness, and well-being aspects, shaped by client values and preferences, and grounded in SDOH.
Individual-, Family-, and Community-Centric Design: Programs prioritize client goals over provider-defined goals, creating “participant-led care environments” and “meeting people where they are,” tailoring interventions to values and cultures at each level.
Relationship-Based Care: Programs emphasize building trusting relationships with individuals, families, and communities to facilitate their engagement in health creation and maintenance.
Ongoing Group and Public Health Approaches: Nurses view serving underserved populations as a moral imperative, using peer education, support groups, and public health strategies to empower clients, build self-care agency, and increase resilience.
In-depth studies of Edge Runner programs highlight collaboration, leadership, scalability, financial sustainability, social support, and empowerment as essential factors. These programs demonstrate nurses’ capacity to build meaningful, sustained partnerships across sectors, impacting health equity. Edge Runner programs showcase nurses actively working to achieve person-centered care, address social needs and SDOH, and focus on underserved populations to promote health equity, striving for improved care, lower costs, and increased patient satisfaction. However, direct evidence linking these programs to disparity reduction is often lacking.
BOX 5-2
Alt Text: Icon denoting a boxed section, indicating examples or case studies that illustrate the concepts discussed in the Edge Runner program description.
As these models evolve, establishing an evidence base to understand their impact on health, well-being, and health equity is crucial. Evaluations of care management programs incorporating social care should utilize both quantitative and qualitative measures beyond healthcare utilization, considering client self-efficacy, satisfaction, and long-term health outcomes. While RCTs provide reliable evidence, they can be limited in scope, potentially missing the multidimensional nature and broader social impacts of these models. Furthermore, the effectiveness of social care models is contingent on the availability of community resources like behavioral health services, housing, and transportation. Programs connecting clients to services cannot succeed if those services are absent. Multisector engagement and interprofessional healthcare teams, including nurses, social workers, community health workers, and physicians, are essential, all working towards a shared goal of improving health and advancing health equity.
Advocating for Policy Change: System-Level Program Implementation
Public policies exert significant influence on healthcare providers, systems, and the populations they serve. Nurses can effectively promote health equity by integrating a health perspective into public policies and decision-making at community, state, and federal levels. Policy advocacy involves communicating about health disparities and SDOH to the public, policymakers, and organizational leaders, highlighting both challenges and solutions for achieving health equity through targeted actions.
When nurses engage in policy change, they address upstream determinants of health, creating a powerful and far-reaching impact on population health. As noted in the National Academy of Medicine’s Vital Directions series, “powerful drivers of health lie outside the conventional medical care delivery system… Health policies need to expand to address factors outside the medical system that promote or damage health.” Because health inequities and SDOH are rooted in social structures and policies, addressing them at their source requires policy change. Nurses cannot solve SDOH problems alone, but by engaging in policy efforts at local, state, or federal levels, using a Health in All Policies (HiAP) approach, they can address SDOH that drive poor health. Whether through full-time policy roles or part-time professional advocacy, nurses’ focus on policies that either create or eliminate health inequities can improve the fundamental conditions shaping health. Nurses can most effectively bring a health and social justice lens to policy decisions by serving in leadership positions across public and private sectors. Nurses should leverage their expertise to champion policies that support health equity.
For example, a nurse in Delaware was instrumental in enacting state legislation for a colorectal cancer screening program, increasing care access and reducing disparities in morbidity and mortality. While individual nurses and professional associations engage in upstream efforts, there are ongoing calls for greater nursing involvement in shaping public policy to improve population health outcomes.
BOX 5-3
Alt Text: Box icon indicating a case example, specifically the Delaware Cancer Consortium, illustrating the impact of policy advocacy on health outcomes.
Conclusions: Nurses as Catalysts for Health Equity
Substantial progress in achieving health equity in the United States by 2030 hinges on dedicating resources and attention to addressing the detrimental effects of SDOH on under-resourced populations. While expanding access to quality healthcare is essential, it must be coupled with efforts to transform the social institutions, dynamics, and systems that underlie health inequities. Nurses are uniquely positioned to reshape the health equity landscape by embracing expanded roles, working in diverse settings, and partnering with communities and sectors beyond traditional healthcare. Many nurses are already active in roles that support health equity, educating and advocating through professional organizations. However, broader engagement as a core nursing activity is crucial to drive nationwide progress. Achieving this requires:
- Supporting nurses in adopting new roles in community settings.
- Ensuring consistent preparation for nurses to address downstream, midstream, and upstream strategies for health equity, tackling issues like geographic disparities, poverty, racism, homelessness, trauma, and behavioral health conditions.
- Increasing experiential learning and community-based opportunities in nursing education to equip nurses with the skills to address complex needs and promote community well-being.
- Moving beyond diversity, equity, and inclusion principles in nursing education to provide sustained, hands-on community and clinical experiences.
- Funding new care models and functions addressing SDOH, health equity, and population health.
- Evaluating models to build evidence for scaling programs and securing necessary resources and policies.
Exemplary programs like the Camden Coalition and Edge Runner initiatives demonstrate the multidisciplinary, multisectoral collaborations needed to address complex needs and achieve lasting impact by eliminating health disparities and advancing health equity. Central to future efforts is rigorous evaluation to build the evidence base for model effectiveness. A critical challenge is finding direct evidence linking nurses’ efforts to address social needs and SDOH with reductions in health disparities. Such evidence is vital for informing payment policies that ensure the sustainability of these models and continued nurse engagement. Through robust evidence, the nursing profession can fully leverage its potential, demonstrating the impact and value of nurse-led initiatives to the public, other professionals, and diverse sectors.
Conclusion 5-1: Nurses are in a position to improve outcomes for the underserved and can work to address the structural and institutional factors that produce health disparities in the first place.
Conclusion 5-2: Nurses can use their unique expertise and perspective to help develop and advocate for policies and programs that promote health equity.
References
(Maintain original references)
Footnotes
(Maintain original footnotes)
