Chapter 20 Part 2 Building a Culture of Health to Influence Health Equity Within Populations

Quintuple Aim and the Role of Nurse-Led Centers

• Quintuple Aim: This framework expands upon the traditional goals of healthcare improvement by adding health equity as a fifth crucial aim, alongside Quality, Population Health, Cost, and Experience. The inclusion of health equity emphasizes the systemic effort to ensure fair and just opportunities for all individuals to achieve their highest level of health, addressing disparities that arise from social, economic, environmental, and structural factors. This expanded aim was brought forth by Nundy, Cooper, & Mate in $2022$, underscoring a contemporary and comprehensive approach to healthcare delivery and improvement.

• Role of Nurse Practitioners and Nurse-Led Centers: Nurse Practitioners (NPs) working in public health settings and within nurse-led centers (NLHCs) are uniquely positioned to be instrumental in, lead, and significantly influence the initiatives and work required to effectively accomplish the goals set out by the Quintuple Aim. Their community-focused approach, emphasis on health promotion, disease prevention, and direct patient care, particularly for vulnerable populations, aligns directly with the objectives of improving population health, reducing costs, enhancing patient experience, ensuring quality, and critically, advancing health equity.

• Learning objective: To differentiate between the three primary types of nurse-led models of care: Comprehensive Primary Health Care Centers, Special Care Centers, and Wellness Centers, understanding how each contributes to the broader goals of the Quintuple Aim.

• NPs in public health and nurse-led centers are well positioned to partner in, lead, and influence the work required to accomplish the Quintuple Aim.

• Learning objective: differentiate between three types of nurse-led models of care: Comprehensive Primary Health Care Centers, Special Care Centers, and Wellness Centers.

Nurse-Led Models of Care

• NLHCs typically fit into one of three service models:

  • Comprehensive primary care centers

  • Special care centers

  • Wellness centers

• Organizational forms vary: many affiliated with an academic setting (school/college of nursing or academic health center); others free-standing with governance by a board; others subsidiaries of larger health care systems, community centers, schools, or other agencies.

• Structural and funding determinants include:

  • Organizational structure (academic vs nonacademic)

  • IRS designation: 501(c)3 nonprofit or Proprietary (for-profit)

  • Reimbursement systems: fee-for-service (with possible sliding-scale), or no charge

• Box 21.3 (NLHC typology) summarizes service models, organizational structures, IRS designation, and reimbursement mechanisms.

Box 21.3 Nurse-Led Center Typologies

• Service Model:

  • Comprehensive primary care centers: health-oriented primary care and public health programs

  • Special care centers: programs targeting specific health conditions (e.g., diabetes) or populations (e.g., frail elderly)

  • Wellness centers: health promotion and disease prevention programs

• Organizational Structure:

  • Academic nurse-led center: affiliated with a school of nursing or academic health center

  • Free-standing center: independent center with its own governing board

  • Subsidiary: part of larger health care systems, home-health agencies, community centers, etc.

  • Affiliated center: legal partnership with health, human services, or other organization

• IRS Designation:

  • 501(c)3: nonprofit

  • Proprietary: for-profit

• Reimbursement Mechanisms:

  • Fee-for-service: payment at time of service; may include sliding-fee scale

  • Federally Qualified Health Center (FQHC): federal designation enabling cost-based reimbursement per encounter

  • Third-party reimbursement: billing to public programs or private insurance

  • Grant funded: federal, state, local, or foundation awards

  • Contributions: individual donations, philanthropic gifts, fundraising

• A small number of NLHCs have FQHC designation with federal funding from the BPHC within HRSA to serve medically underserved populations (Auerbach et al., 2013; Hansen-Turton et al., 2015). FQHCs may be designated as community health centers, migrant health centers, public housing centers, homeless centers, or school-based health centers.

• FQHC designation benefits:

  • Supports serving low-income and uninsured populations and fiscal solvency

  • Renewable federal grant funds for operational expenses

  • Cost-based payment for services to Medicare/Medicaid recipients

  • Federal Tort Claims Act (FTCA) coverage

  • 340B drug pricing to reduce pharmaceutical costs

  • Public Health Service Act provision enabling financial help for hospitals serving vulnerable populations

  • Recruitment options via National Health Service Corps and Nurse Corps scholarships/loan repayment programs

NLHCs and Academic/Clinical Integration

• NLHCs affiliated with schools of nursing or academic health centers integrate service, education, and research (Johnson, Patel, & Talley, in press).

• These clinics leverage public health and primary care NP educational programs, faculty expertise, and rich learning experiences for nursing students at all levels.

• Collaboration across disciplines (social work, PT, dentistry, optometry, medicine, business, communications, and law) expands service capacity.

• Increasing IPCP adoption in nurse-led care:

  • IPCP defined as multiple health workers from different professional backgrounds working with patients, families, and communities to deliver high-quality care (WHO, 2010, p. 13).

  • IPEC competencies require integration of four domains: $ext{values/ethics}; ext{roles/responsibilities}; ext{interprofessional communication}; ext{teamwork}$ (IPEC, 2016).

  • Team members come from different disciplines, value each other’s contributions, and understand each other’s potential to enhance care quality and safety (Shirey et al., 2021).

  • IPCP fosters teamwork, care coordination, and smooth transitions across levels of care (Shirey, White-Williams, & Hites, 2019; White-Williams & Shirey, 2021).

• IPCP vs Multidisciplinary care:

  • IPCP: colocated, integrated, team-based, full responsibility for the patient’s full plan of care, emphasis on outcomes, and population-level care coordination (Table 21.1).

  • Multidisciplinary: professionals work in parallel, not typically colocated, may have episodic plan of care, and less integrated teamwork.

Table 21.1 (Conceptual Summary)

• Multidisciplinary Practice:

  • Multiple professionals working together but not in close contact

  • Generally, only professionals contribute to the care delivery model

  • Fragmented, parallel work; not necessarily team-based

  • Various professionals assume responsibility for parts of the patient plan of care; each discipline achieves its own goals

  • Plan of care may be episodic and not necessarily collaborative

• Interprofessional Collaborative Practice (IPCP):

  • Multiple professionals working together, usually in close proximity

  • Includes a range of personnel from licensed professionals to lay community health workers

  • Integrated work with a team-based identity

  • Full team assumes responsibility for the patient’s full plan of care; team relies on each other and collaborates to accomplish care goals

  • Plan of care is integrative and follows patients and families

Special Care Centers

• Learning objective: describe the focus of the special care centers model, including House Calls Programs, Transitional Care Home Visits, and Nurse-Family Partnership models.

• Some NLHCs focus on a specific demographic or health care need. Special care centers provide services and specialized health knowledge for targeted groups, yet may also provide comprehensive primary care to those groups.

• Examples of special care centers: focus on diabetes, heart failure, HIV/AIDS, women who have been victims of human trafficking, the frail elderly, or supports for people with mental or developmental disabilities.

• Other centers act as hubs for public health nursing in home/community settings, including:

  • House Calls Programs

  • Transitional Care Home Visits

  • Nurse-Family Partnership (NFP) models

  • Early childhood home visiting models (e.g., Parents as Teachers [PAT], Early Head Start)

• Fig. 21.1 illustrates advanced practice nurses and undergrad nursing students caring for adults with developmental disabilities.

House Calls Program

• House calls provide home-based primary or end-of-life care for vulnerable patients who cannot travel to a clinic (e.g., frail elderly, homebound).

• Team composition often includes NP or physician leads, plus social worker, medical assistant, RN, and others tailored to the patient’s needs.

• Visit components typically include: medical history review, physical exam, medication review, social services assessment, education, and discussion of health concerns.

Transitional Care Home Visits

• Transitional care home visits occur within the first $7$ days after hospital discharge and before the first clinic appointment.

• A social worker and a nurse (transitional care coordinator) conduct the visit.

• Purpose: address immediate post-discharge needs, review medications, and perform social services assessment.

• The home visit team communicates with the NP/physician before the first clinic appointment to support continuity of care and reduce rehospitalization, especially for high-risk, vulnerable clients.

Nurse-Family Partnership (NFP)

• NFP is an evidence-based community health program for first-time, low-income parents and their children via an intensive home-visit model aimed at promoting health equity and reducing disparities.

• Origin: developed by David Olds; more than $45$ years ago (NFP, 2022).

• Model: eligible low-income women enroll during pregnancy; each woman receives intensive home visits by a bachelor’s-prepared RN until the child reaches age $2$ (64 home visits total; program graduation).

• Goals: improve pregnancy outcomes, improve child health and development, and enhance family economic self-sufficiency over time.

• Home visitors receive extensive training in NFP protocols, maternal-infant-toddler assessment measures, and motivational interviewing.

• Geographic availability: $40$ states, plus Washington, D.C., and the U.S. Virgin Islands (NFP, 2022).

• Fig. 21.2 depicts a public health nurse conducting a home visit.

Wellness Centers

• Learning objective: describe the focus of the wellness center model.

• Focus: health promotion, disease prevention, and management programs.

• Services may include outreach, public awareness, health education, immunizations, family assessment and screening, home visiting, and social support services.

• Enabling services help access language translation, entitlement program registration, transportation vouchers, and specialty services.

• Alignment with Healthy People 2030 goals and objectives to guide planned, implemented, and evaluated services.

• Wellness centers complement existing primary care services and maintain strong relationships with local providers in community health centers, clinics, private practices, long-term care facilities, and other organizations.

• Funding typically comes from public health departments, foundation grants, fee-for-service, voluntary contributions, or shared resources from affiliated organizations.

• Wellness centers often host community service-learning activities for graduate and undergraduate students across disciplines.

Linking Content to Practice

• This chapter emphasizes how nurses deliver care and public health services within nurse-led settings, whether in clinics, communities, or home visits.

• Core nursing process skills (assessment, planning, implementation, evaluation) and policy development are essential to this role.

• Vision: progress toward social justice and health equity or population health for all.

• Quad Council Coalition of Public Health Nursing Organizations (Alliance of Nurses for Healthy Environments; Association of Community Health Educators; Association of Public Health Nurses; American Public Health Association - Public Health Nursing) contributed updates to Public Health Nursing Competencies in $2018$.

• With considerations from the COVID-19 pandemic and the new Essentials: Core Competencies for Professional Nursing Education (AACN, $2021$), updates to core competencies for Public Health Nurses will be needed. In the meantime, the following core competencies guide practice:

  • Quad Council Public Health Nursing Competencies (2018) accessed at the Council on Linkages/Council resource

  • AACN: Public Health Baccalaureate Competencies and Curricular Guidelines for Public Health Nursing (2013)

The Team of a Nurse-Led Center

• Learning objective: describe the roles and responsibilities of collaborative team members and other key roles in the nurse-led health center.

• Collaborative team roles may include:

  • Nurse Practitioners (NPs)

  • Clinical Nurse Leaders (CNLs)

  • Social workers

  • Registered nurses (RNs)

  • Medical assistants (MAs)

  • Collaborating and specialty physicians

  • Behavioral health specialists

  • Dietitians

  • Pharmacists

  • Support personnel

• Staffing patterns depend on clinic type, services offered, and reporting lines. An organizational chart should clearly delineate positions and reporting relationships.

• The organizational framework should be dynamic and adaptive to new community-focused initiatives.

• A clinic’s success hinges on positive collegial and professional relationships and alignment with population needs (Slusser, Garcia, Reed, & Quinn, 2018).

Nurse Practitioners (NPs)

• NPs hold a master’s or doctoral degree with advanced clinical training beyond basic nursing.

• Licensing: NPs can be licensed in all $50$ states plus the District of Columbia.

• Scope of practice: determined by state regulations and NP certification (education-based).

• Care across the continuum (inpatient and outpatient) for diverse populations (neonates, pediatrics, adolescents, adults, geriatrics, women) and various specialties.

• Examples by population/needs:

  • Acute, emergent, critical care: adult/gero or pediatric NPs

  • Chronic care, health promotion, health maintenance: family NPs, adult-gero primary care NPs, pediatric primary care NPs

  • Psychiatric-mental health needs: psychiatric-mental health NPs

  • Women’s health: women’s health NPs

• In nurse-led clinics, NPs provide direct patient care (in-person or telehealth) and oversee daily clinic operations and workflow, applying nursing and public health principles to promote population health.

• NPs often supervise clinical staff responsible for program services and outcome measures.

Care Coordinators

• Role essential to IPCP and the care continuum; coordinates smooth transitions across care settings.

• Role may be filled by a nurse (RN or CNL) or a social worker (Zerden et al., 2020).

• The CNL (Clinical Nurse Leader) is a master’s-educated generalist who can function as a transitional care coordinator, quality coordinator, and education specialist (Hulett & Shatto, 2021).

• CNLs work with NPs to implement group health education classes and screenings, and provide individual case management in clinic, community, and home settings.

Social Workers

• Social workers are an integral part of the collaborative team (Zerden et al., 2020).

• Licensure varies by state and degree level:

  • Bachelor’s degree: licensure available in some states

  • Master’s degree: Licensed Master Social Worker (LMSW)

  • Doctoral or advanced degrees: Licensed Independent Clinical Social Worker (LICSW)

• NASW 2022 guidance: LMSWs typically require supervision; LICSWs can practice independently focusing on assessment, diagnosis, treatment, and prevention of mental health disorders and other emotional/behavioral issues.

• Social workers address social determinants of health and coordinate with health care teams to address needs such as:

  • Food insecurity

  • Access to medications

  • Transportation

  • Housing and environmental safety

  • Behavioral health counseling

  • Employment and insurance access

  • Social support

Other Collaborative Team Staff

• Teams may include additional roles as needed by the patient population and services offered (e.g., licensing requirements, specialty staff).

Interprofessional Education and Practice: Competencies and Implications

• IPCP relies on competencies from IPEC (values/ethics; roles/responsibilities; interprofessional communication; teamwork) to ensure integrated, team-based care.

• IPEC competencies emphasize mutual respect, understanding of each profession’s contributions, and coordinated care planning.

• The goal is to realize improved patient outcomes, patient safety, better care coordination, and enhanced health equity.

Practical and Ethical Implications

• Ethical considerations include equitable access, justice in distribution of resources, and ensuring culturally competent care within IPCP teams.

• Practical implications involve organizational design (dynamic, adaptive), funding strategies (FQHC status, grants, contributions), and sustainable care coordination models to reduce hospitalizations and improve population health outcomes.

Key References and Foundational Concepts

• WHO (2010) on IPCP definition: Multidisciplinary teams from different backgrounds collaborating with patients and communities for high-quality care. $2010$

• IPEC (2016) on IPCP competencies. $2016$

• Quad Council for Public Health Nursing Competencies (2018). $2018$

• AACN (2013) Public Health Nursing competencies and curricular guidelines. $2013$

• NFP program details and impact on health equity. $2022$

• HRSA BPHC and the FQHC designation benefits and federal funding mechanisms. $2013,$2015$</p></li><li><p>Healthy People 2030 goals guiding wellness center activities.$2030$</p></li><li><p>Figure references:</p><ul><li><p>Fig. 21.1: care by advanced practice nurses and students for adults with developmental disabilities.</p></li><li><p>Fig. 21.2: Nurse-Family Partnership home visit scenario.</p></li></ul></li></ul><h4 id="e764144e-1b63-4fa0-8f1c-52968e577db2" data-toc-id="e764144e-1b63-4fa0-8f1c-52968e577db2" collapsed="false" seolevelmigrated="true">Summary of Core Concepts to Memorize</h4><ul><li><p>The five aims of health care improvement, including health equity as the Quintuple Aim.</p></li><li><p>The three nurse-led model types and how they differ in service focus, structure, and reimbursement.</p></li><li><p>The FQHC designation and its benefits for NLHCs serving vulnerable populations.</p></li><li><p>IPCP versus multidisciplinary care and why colocated, integrated, team-based approaches improve outcomes and equity.</p></li><li><p>The core roles within a nurse-led center: NP, CNL, care coordinators, social workers, RNs, MAs, and allied professionals.</p></li><li><p>The pragmatic examples of special care centers: House Calls, Transitional Care Home Visits, and NFP; their aims and operational timelines (e.g., 7-day post-discharge window for home visits).</p></li><li><p>Wellness centers as venues for health promotion, training, and community engagement, aligned with Healthy People 2030.</p></li><li><p>The integration of education, research, and clinical care in academic-affiliated NLHCs and the importance of service-learning.</p></li><li><p>The ethical and practical implications of staffing, funding, and delivering care across the continuum in diverse communities.</p></li></ul><h4 id="658e74ce-ff3e-4b1e-aeb4-56e98556359b" data-toc-id="658e74ce-ff3e-4b1e-aeb4-56e98556359b" collapsed="false" seolevelmigrated="true">Connections to Prior Knowledge and Real-World Relevance</h4><ul><li><p>IPCP aligns with foundational public health principles of team-based, coordinated care and the social determinants of health.</p></li><li><p>FQHCs illustrate how policy and funding structures shape access to care and the financial viability of community-based health services.</p></li><li><p>The Nurse-Family Partnership exemplifies how evidence-based home-visiting programs can generate long-term health and economic benefits for families, informing policy and practice in maternal-child health.</p></li><li><p>Wellness centers illustrate the shift toward preventive care and community-based health promotion, complementing traditional primary care models and supporting population health goals.</p></li></ul><h4 id="26e465e0-0fc7-467e-807d-341e83f18a7e" data-toc-id="26e465e0-0fc7-467e-807d-341e83f18a7e" collapsed="false" seolevelmigrated="true">Formulas and Numerical References (LaTeX)</h4><ul><li><p>Number of NFP home visits:$64$</p></li><li><p>Duration of NFP involvement: from pregnancy to child age$2$years</p></li><li><p>Availability of NFP:$40$states +$ ext{DC}$+$ ext{USVI}$</p></li><li><p>Post-discharge home visit window:$7$days</p></li><li><p>Competency domains in IPCP (IPEC, 2016):$4$domains</p></li><li><p>Years and policy references:$2010$(WHO IPCP definition),$2016$(IPEC competencies),$2018$(Quad Council competencies),$2021$(AACN Essentials update),$2022$$ (NFP year and sources)

Note on Figures and Tables

• Box 21.3 summarizes Nurse-Led Center Typologies (Service Model, Organizational Structure, IRS Designation, Reimbursement).

• Table 21.1 contrasts Multidisciplinary Practice with Interprofessional Collaborative Practice (IPCP).

• Fig. 21.1 shows care delivery for adults with developmental disabilities by advanced practice nurses and students.

• Fig. 21.2 shows a Nurse-Family Partnership home visit example.