Chapter 7: Community Health Planning & Evaluation

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Welcome back to The Deep Dive.

We are so glad you are here with us today.

Whether you are, you know, walking the dog, commuting to clinicals, or sitting at your desk with a highlighter in hand, we are ready to get into it.

We are.

And today's topic, it requires a bit of a mental gear shift.

It really does.

Usually when we think about nursing or healthcare in general, we picture a bedside scenario.

One patient, one nurse, a chart, a specific set of vital signs.

It's all very immediate, right?

It is.

It's usually patient A has symptom B, so we administer treatment C.

It's very linear in focus.

Exactly.

But today, we are grabbing the wide -angle lens, we are gleaming out.

Right.

We're looking at chapter seven, community health planning, implementation, and evaluation.

And that's a significant shift in perspective.

We're moving from the individual patient to this concept of the community as a client.

And the mission for this Deep Dive is to guide you, whether you're a nursing student prepping for an exam or just a learner curious about public health, through that entire nursing process as it applies to whole populations.

Right.

We're going to cover the models, the legislation, the history, and some really, really fascinating case studies,

all exactly as they're laid out in the text.

The thing is, and this is what's so important to remember, the skills you use at the bedside assessment, planning, intervention, evaluation.

They're the exact same skills.

The exact same.

The scale just changes dramatically.

So to kick things off, I don't want to start with dry definitions or theory.

I want to start with a story.

A story from the text that I think just illustrates why all of this matters.

It's clinical example 7 .1 about a school nurse named Maria Gutierrez.

Ah, yes.

This is a classic example of what we call the detective work in community nursing.

It really sets the stage for everything else we're going to talk about.

It does.

So let's paint the scene.

Maria is an RN.

She's working in a suburban middle school.

Now just pause there for a second.

When you think suburban middle school, what comes to mind?

Relative safety, quiet, you know, stability.

You don't immediately think public health crisis.

Not at all.

But Maria is paying attention.

She starts noticing something alarming in her daily practice.

She's seeing a spike,

a real spike in student visits related to sexually transmitted diseases or STDs.

And this is the critical moment.

A bedside nurse might just treat the individual students, you know, give them their referrals, send them back to class and document it.

And that would be the end of it.

Right.

But Maria didn't do that.

She started digging.

That's the shift.

She stopped looking at the individual trees and started looking at the whole forest.

She went to the literature.

She looked at nursing journals, internet sources to see if this was just her school, maybe a localized outbreak, or if this was part of something bigger.

And what she found was frankly pretty startling.

It was.

There was a national increase in STDs among young adolescents.

And the data she pulled from the CDC, the Centers for Disease Control and Prevention, it painted a very specific and very worrying picture.

I think we need to walk through those stats because they really define the risk landscape she was dealing with.

We do.

So the CDC reported that 41 % of high school students had ever had sexual intercourse.

Okay, so that's a significant baseline to start with.

But the risk factors, that's where my jaw dropped.

Exactly.

So of those sexually active students, 43 % did not use a condom the last time they had sex.

Nearly half.

Nearly half.

And then 14 % used no method of pregnancy prevention at all.

And then you add the impairment factor on top of that.

Right.

21 % had used alcohol or drugs before their last sexual encounter.

So you have a situation with impaired judgment, lack of barrier protection, and a lack of contraceptive use all happening at once.

And here's the kicker for me, the one I found most concerning.

Only 10 % of sexually experienced students had ever been

Which is just a massive gap in care.

I mean, it means you have a whole population just flying blind when it comes to their HIV status.

And the risks here are not small.

We're talking HIV, other STDs, and unintended pregnancy.

The text makes a point to note that nearly 230 ,000 babies were born to teen girls aged 15 to 19 in 2015 alone.

So Maria has all this national data.

She knows the what.

But now she needs to figure out the why.

Specifically, the why for her school.

Yes.

This is where her assessment moves from national statistics to the specific barriers in her local community.

And she identified a few key things.

She did.

First, she noticed that LGBT sexual health issues were just completely ignored.

Not part of the school culture, not part of the conversation.

And second, the teens had this invincibility complex.

It's that classic adolescent mindset of it won't happen to me.

They just didn't believe they could actually get sick.

But even for the ones who might have been worried, there were real structural barriers in their way.

Big ones.

Maria found that students were just plain embarrassed to buy protection at local stores where their parents or neighbors might see them.

But more importantly, when she looked at the super system, and we'll define that term in detail later, there was no local family planning clinic, not one, in the entire suburb.

Zero access.

And on top of that, local doctors were really reluctant to treat teens without parental permission.

So even if a student managed to get an appointment, the doors were effectively locked.

And there was history there, too.

This is the political context that's so crucial.

It is.

A few years prior, parents in the community had actually blocked the school board from establishing a sex education program.

They felt that topic belonged strictly in the home, not in the school.

That is such a critical piece of the puzzle.

You absolutely cannot plan an intervention without understanding the political and social history of the community.

If you ignore that past conflict, you're basically walking into a minefield.

Completely.

So what did Maria do?

She didn't just stand up and start lecturing students about condoms.

She developed a plan that involved everyone.

She met with teachers, with school officials, and crucially, with the parents.

And by meeting with them, she found that the parents weren't necessarily against safety.

They were just uncomfortable discussing it themselves.

They wanted to be involved in planning the curriculum.

And they wanted it to be about more than just the mechanics, right?

Exactly.

They wanted the focus to include moral decisions and healthy relationships.

That was their main concern.

That's a huge distinction.

And by listening to that, she got their buy -in.

It wasn't an us versus them situation anymore.

And then she made a brilliant strategic move to address that resource gap.

She reached out to an urban family planning agency and asked them to open a part -time clinic right there in the suburb.

Which is just, it's a perfect encapsulation of why we're studying this chapter.

Maria's story links an individual health outcome, like a teenager getting an STD to these broader socioeconomic environmental factors.

It demonstrates that health planning is complex, it is time -consuming, and it absolutely requires community involvement.

You cannot do it alone.

Which brings us squarely to section one of our outline, the concept of community as client.

And this is often a stumbling block for students, I find.

They worry that by focusing on the community, on the big picture, that they're somehow neglecting the individual patient in front of them.

Right.

It can feel impersonal or like you're losing that one -on -one connection.

But the text makes a really important point to clarify this.

It's not about ignoring the person in front of you.

Not at all.

It's about using community data to understand that person better.

Can you give an example of that?

Sure.

If you know from your community assessment that there are high lead levels in the local water supply, you're going to treat the child in front of you who comes in with a stomach ache differently.

You'll immediately think to check for lead poisoning.

The community data informs your individual care.

And this concept, it isn't new either.

We have to give a nod to the history here,

to Lillian Wald.

Absolutely.

Back in the late 1800s at the Henry Street Settlement in New York City, she was the pioneer of this.

She was working with extremely poor immigrant populations, right, in the tenements.

Yes, exactly.

And she quickly realized she couldn't just treat their pneumonia or their tuberculosis.

She had to improve their environment, the sanitation, the overcrowding, the working conditions.

That is the root of community as

you treat the environment to save the patient.

Precisely.

The text gives us a visual for this, figure 7 .1.

And it's described almost like a beehive.

I love this imagery because it really helps you visualize all the connections.

It's a great visualization.

So picture a honeycomb.

In that center cell, you have the community health nurse.

Okay.

But surrounding that center cell, touching it on all sides, are all these other cells that represent interacting factors.

And factors like geography,

population,

the environment, industry, education, religion, politics, transportation, all of it.

The takeaway from that image is that the nurse doesn't operate in a vacuum.

You have to assess the entire aggregate.

That's the word for the group you're treating to plan effective interventions.

You have to look at the education cell and the transportation cell and the politics cell to really help the people who are in the center.

Right.

Because if the transportation cell is broken, the patient can't get to the clinic you set up.

It is all connected.

Okay.

So let's unpack the tool we use to do all of this.

We're moving into section two, the health planning model and systems theory.

Right.

So this model, it's based on Hoag's group intervention model from way back in 1985.

The goal is pretty straightforward.

Improve the health of the aggregate.

And you do that by applying the The same nursing process everyone learns in nursing 101.

Assessment, planning, intervention, and evaluation.

But here, we wrap it in something called the systems theory framework.

Okay.

And box 7 .2 in the text breaks this down.

I think it's really important you walk us through the three critical levels of a system, because this vocabulary is going to come up again and again.

It is.

It's essential for any kind of analysis.

So you have three levels.

First, you have the system.

This is the group that you're actually studying.

The aggregate.

The aggregate.

Exactly.

Let's use the example from the text.

A group of incarcerated women.

That group is the system.

Okay.

So the system is the target population.

What's inside that system?

Inside, you have the subsystem.

These are the individual parts within the system.

So in our example, the individual women in the prison are the subsystems, their personal health, their attitudes, their relationships with each other.

That's the subsystem level.

And then outside of it.

That is the supersystem.

This is the environment the system interacts with.

So for the incarcerated women, the supersystem would be the Department of Corrections or the State Social Services or the prison administration itself.

It's the larger context.

That hierarchy is so helpful.

Yeah.

Subsystem is the individual.

System is the group.

Supersystem is the environment or the authority that governs them.

You've got it.

And all systems have

boundaries.

They can be open or closed to outside information.

Prison is a very closed system, for example.

They have goals, usually survival or growth, and they have processes like how they make decisions or adapt to change.

So before you can even start analyzing a system, you have to pick one.

The text talks about choosing an aggregate.

How does a nurse actually decide who to help?

Well, it's a mix of community need and honestly, personal strength.

The text gives the example that an urban industrial area might have a high need for occupational health, while a suburb might need more help with, say, family clubs or the PTA.

But it also says the nurse should consider their own preferences, right?

It's not just about the data.

Absolutely.

And I think this is really important permission for the nurse to hear.

If you love teaching, maybe you should choose a school setting.

If you're a great organizer, maybe you should work with a community board.

If you love working with the elderly, you focus there.

Exactly.

You need to play your strengths because this work is so relationship based.

If you aren't passionate or comfortable with the group you've chosen, you're just not going to be as effective.

Okay, so let's say we've done that.

We've chosen our aggregate.

We're now at the starting line.

Section three, step one assessment.

This is where the rubber meets the road.

And the very, very first step of assessment is something called gaining entry.

That sounds like we're breaking into a secure facility or something.

In a way, you are.

You're breaking into a social circle, a pre -existing community.

You can't just walk in with a clipboard and start asking questions and measuring things.

You must be invited or, at the very least, accepted.

So how do you do that?

How do you gain entry?

Professionalism is absolutely key.

You have to clearly state your position, your organizational affiliation, and what skills you bring to the table.

But mostly you have to build trust.

It's all about the relationship.

The text is very, very clear on this point.

If you do not establish a relationship, the assessment will fail, period.

If they don't trust you, they won't give you real information and all the data you collect will be basically garbage.

So once you're in, you start the socio -demographic assessment.

This is the hard data.

The age, sex, race, religion, education, income.

Why do these specific data points matter so much?

Because they dictate your entire approach.

The text gives some great examples.

If your assessment shows you're working with adolescents, you know instinctively that they need small group involvement.

They do not respond well to lecture.

No, they tune right out.

But if you're working with adults,

their education and literacy levels are going to dictate whether you use a formal or an informal setting.

If you prepare a beautiful PowerPoint presentation filled with academic language for a group that struggles with literacy, you have failed before you've even started.

So where do we get all this data?

A few different places.

Observation is huge.

Just looking around with a critical eye.

Consulting other workers like a factory nurse or a teacher who's been in that school for 20 years.

Reviewing existing records.

But there's one concept the text highlights that I absolutely love.

It's the key informant.

I love that term.

It sounds like something out of a spy movie.

Who is a key informant?

A key informant is a formal or an leader in the community who provides you with insider data.

It's information based on their personal knowledge and experience.

This could be a priest, a matriarch of a neighborhood, a barber, a local shop owner.

They're the gatekeepers of the real story.

That's the perfect way to put it.

They know things the official statistics will never tell you.

They know why people don't go to that clinic on 4th Street.

They know the history of the neighborhood feuds that prevent collaboration.

You need them on your side.

Okay.

So next in the assessment process, we analyze the health status.

This seems a little tricky because the text says you have to look for both positive and negative factors.

Yes.

And you have to be really careful with your interpretation here.

Let's take something like absenteeism from work or school.

Low absenteeism might mean everyone is healthy.

That's a positive factor.

A community strength.

Or it might mask the fact people are coming to work sick because they don't have paid sick leave and can't afford to stay home.

That would be a negative factor that's disguised as a positive one.

You have to dig deeper than the surface number.

And contextual norms matter a lot here too.

Correct.

Immunization rates are a key health metric for children, but you wouldn't use that same metric for a group of adults.

For the elderly, you might look at flu vaccine rates or statistics on falls.

You have to match the group you're assessing.

And as part of this, we also have to assess the super system.

We have to look at what resources already exist.

Right.

You don't want to reinvent the wheel.

Is there a hospital nearby?

Meals on Wheels program?

Is there public transportation?

And you also do a literature review.

You compare your aggregate to the norm.

So you'd ask, is the rate of respiratory infections at this Head Start Center higher than the national average for Head Start Centers?

Exactly.

If the yes, you've just identified a significant problem that needs to be addressed.

And that leads us perfectly to the needs assessment.

The text cites a taxonomy of four different types of needs.

And I think it's really important we define these clearly because they help you understand what you're actually seeing when you're out in the community.

Let's break them down.

First up is expressed need.

This is basically the demand for services.

It's market behavior.

People are lining up for something.

They're actively asking for it.

Okay.

So express need equals demand.

What's number two?

Second is normative need.

This is a lack or a deficit that's determined by experts, by doctors or nurses.

An expert looks at the data and says, this community has a deficiency in iron.

The community itself might not be aware of it, but the expert identifies it based on evidence.

Normative need is the expert opinion.

Got it.

Third.

Third is perceived need.

This is what the population wants or prefers.

This is their voice.

They might say, we need better lighting in the park so our kids can play safely after school.

Perceived need is the community want and the last one.

And fourth is relative need.

This is the gap or the disparity between an advantaged group and a disadvantaged group.

It's the, why does the town across the river have a brand new swimming pool?

And we don't.

Relative need is the gap.

Okay.

So once you've gone through this whole process and you have this long list of needs, you have to

fix everything at once.

And prioritization is a critical, critical skill.

You look at the aggregate's preferences.

What do they care about most?

You look at the number of people affected by the problem, the severity of the problem, and very importantly, whether a solution is even available and feasible.

The text gives us two frameworks for this,

Maslow and Lavelle and Clark.

Right.

So Maslow's hierarchy of needs reminds us to address lower level needs first.

You can't run a workshop on self -actualization and art appreciation if people are starving or don't feel safe in their homes.

You start with the basics.

You start with the basics.

And Lavelle and Clark's levels of prevention, primary, secondary, and tertiary remind us to think about where we can make the most impact.

We should always be aiming for primary prevention whenever possible.

Okay.

So we've assessed.

We know what's wrong.

Yeah.

Now we move to section four, step two in the process, which is

planning.

And the golden rule here, the one quote you should write down and stick on your monitor comes from Niswander in 1956.

Start where the people are.

That sounds so simple, but it implies a whole lot.

It implies respect.

It implies that you don't come in with your own agenda, your own pre -baked solutions.

You start with their reality, their perceptions, their culture.

And this ties directly into the concept of empowerment.

The text talks about Labonte's 1994 empowerment model.

Yes.

Labonte argues that the community is the engine of health promotion.

The nurse is just the facilitator.

He describes five spheres of empowerment, and it's almost like a ladder you climb.

It is.

It starts with the interpersonal.

That's personal empowerment.

Then you move to the intergroup small group development,

then intergroup community collaboration, then interorganizational building coalitions with other groups.

And finally you get to political action.

So it's a progression that starts with building confidence in one person and can end with changing the laws for the entire city.

And it requires what we call an upstream focus.

We want to address the underlying pauses, not just the downstream symptoms.

We don't just want to hand out asthma inhalers.

We want to clean up the air pollution that's causing the asthma.

So in the planning phase, a big part of this is writing goals and objectives.

I feel like this is something people always confuse.

They do all the time, but the distinction is actually pretty simple.

A goal is where you want to be.

It's the ultimate outcome.

It's the destination on the map.

It's big and broad.

Right.

An objective, on the other hand, is the specific measurable step you take to get there.

It's the turn by turn directions.

It's an instruction on what the population will actually do.

Box 7 .3 gives a fantastic example related to childhood obesity.

Let's look at that.

The goal was reduce obesity in the city of New Bedford.

Very big picture.

But the objectives were very, very specific.

They invited children to a program called 521.

Right.

And look at how measurable these are.

Five servings of fruits and vegetables per day, a two -hour limit on screen time, and one hour of physical activity.

Reduce obesity is vague.

Eat five fruits today is something you can actually count.

That is the difference.

Precisely.

And once you've planned your interventions, you have to validate them.

You have to ask the hard questions.

Is this plan practical?

Do we actually have the resources, the time, the money, the people to pull this off?

You have to make sure your plan is doable before you launch it.

Which moves us on to section five.

Step three intervention and step four evaluation.

The intervention stage is often called the fun part.

It's where you finally get to do the work.

You implement the plan you spent so much time developing.

But the text has a big warning here.

Be prepared for the unexpected.

Always.

Community work is messy.

It's not a fair.

Transportation issues can mean nobody shows up to your workshop.

A flu outbreak can cancel a community gathering for weeks.

You have to be flexible and adaptable.

What are some common strategies for intervention?

Oh, there are many.

Mass media campaigns,

electronic dissemination through social media, public forums and town halls.

Really, whatever method best reaches the people you're trying to serve.

And then comes the final step.

Evaluation.

Did it actually work?

And not just did it work, but why did it work or why didn't it?

We look at two main types of evaluation.

The first is process evaluation.

It's also called formative evaluation.

And that happens during the project, right?

Not at the end.

Exactly.

You're constantly reflecting on the plan's strengths and weaknesses while you're doing it.

Was our initial assessment adequate?

Did we involve the community enough in the planning?

It allows you to pivot and make changes on the fly.

And the very end.

Did we meet those specific measurable objectives we set?

Did the obesity rate actually drop?

Was it cost effective?

Before we get to the case studies, there's a research highlight in this section about pesticides on athletic fields that I found really fascinating.

It is a striking study.

It looked at 101 athletic fields in Maryland and they found that 66 % two thirds of the fields used pesticides.

And there was a weird twist, right?

Rural fields use more than urban ones.

They did.

And the implication is really serious.

Children play on these fields every single day.

They have much higher exposure risks to these chemicals because of how they play and, you know, their physiology.

So what does that mean for the nurse?

It means we have to question policy and practice regarding environmental hazards.

It's a perfect example of a super system issue, the school district's maintenance policy directly affecting the subsystem, the individual child's health.

Now let's get into the stories.

Section six, case studies.

The text gives us some clear wins and some clear losses.

And I think these are the best way to learn what not to do.

Let's start with the success stories though, to build up some confidence.

Okay, good call.

Successful project number one, the textile industry.

Right.

So this was a nursing student doing a clinical rotation in a plan with 470 employees.

The student did a really thorough adjustment and identified three main problems.

A high rate of lower back injuries,

possible hypertension among the staff,

and a really disorganized chaotic first aid system.

What I love about this one is the multi -level intervention.

It touches on everything we've talked about.

It does.

At the super system level, the student lobbied management for proper lifting training and helped create new job descriptions to prevent injury in the first place.

So she changed policy.

Then at the aggregate level, she set up a retention screening and actually found 10 people with dangerously high blood pressure who didn't know it.

Wow.

And at the subsystem level, the student just physically went in and organized all the first aid supplies, made sure everything was stocked and easy to find.

It covered all the bases and the outcome.

Management was so impressed they hired the student as the new occupational health nurse as soon as she graduated.

That is the definition of a successful clinical rotation.

Okay, successful project number two,

the rehabilitation group.

This one was with homebound seniors.

The student's assessment showed they were suffering from profound social isolation.

They desperately needed socialization.

So what was the intervention?

It sounds like a complex problem.

It was actually simple but incredibly effective.

The student just organized van transport for a weekly get -together program coffee, a shared meal, and some light chair exercises.

Increased socialization.

Even though one person ended up withdrawing from the group, overall it functioned really well and met that core need.

It just goes to show that sometimes the best intervention isn't medical at all.

It's social.

Now for the hard lessons, let's look at the failures.

These are so instructive because they show exactly where things can go wrong in the nursing process.

Unsuccessful project number one, the group home for developmentally Oh, this one hurts to read.

So the plan was a weight reduction program.

The students saw the clients were overweight and just decided to fix it.

But not a single person lost weight.

In fact, some of them gained weight.

So why?

It failed right at the beginning at the assessment phase.

Exactly.

The student never considered the client's perceptions of their own weight.

The women in the group home did not view their weight as a problem.

In fact, the text notes that their boyfriends reinforced their current size.

So the student imposed a normative need,

her expert opinion that they should lose weight,

that directly clashed with the perceived need or lack thereof of the clients themselves.

A classic mistake.

You can't solve a problem that the community doesn't believe exists.

Okay.

Unsuccessful project number two, the safe rides program.

This one started out great.

The assessment was solid.

77 % of students at this college admitted to driving under the influence.

A huge problem.

So the student organized a safe rides program, volunteers driving intoxicated students home.

And it worked for a while.

It worked until the student graduated.

And that's where it failed in the planning and sustainability phase.

The text says the student was the prime motivating force.

She was the engine and she never arranged for a replacement leader.

So when she left,

the program just died.

It completely fell apart.

It's a classic failure of succession planning.

You have to plan for what happens when you are no longer there.

That's a tough one.

Okay.

Last one.

Unsuccessful project number three, the manufacturing plant back injury project.

This one is all about the super system.

The plan itself was good.

A body mechanics class held during coffee breaks to help prevent back pain.

Smart.

But it failed at implementation due to factors completely outside the student's control.

The union contract negotiations.

Exactly.

The negotiations caused a lot of tension between the workers and management to avoid any potential for strikes or disruptions.

Management canceled all non routine activities, including the student's class.

The lesson here is that even with a perfect plan, the political context, the super system can completely block your intervention.

You have to be aware of the larger forces at play.

Such valuable lessons in failures.

Let's zoom back out to the theoretical level again for section seven, health planning models and public health.

Right.

So over the years, we've evolved from very simple environmental planning, like building water and sewer systems to much more systematic models for behavior change.

And the big one here is the precede proceed model by green and Croyder.

That's a mouthful.

Let's break that acronym down quickly.

Okay.

So precede is the planning phase.

It's an assessment acronym.

It tells you to assess three types of factors.

First, predisposing factors.

This is the knowledge, attitudes and beliefs that exist before your intervention.

What do people already think?

Second, enabling factors.

This is the environment that facilitates or blocked change.

Are there gyms?

Is healthy food affordable?

And third, reinforcing factors.

This is the feedback or social support they get after they try to adopt a new behavior.

Do their friends and family support their decision to quit smoking?

So that's precede.

What's proceed?

Proceed is the implementation and evaluation part of the model.

It stands for policy regulation and organization.

It's how you connect your detailed plan to the real world of policy and structure.

The text also briefly mentioned a few other models like pat TCH, right?

The planning approach to community health, which really emphasizes community participation, MAPP, MAPP, or mobilizing for action through planning and partnerships,

which has a unique focus on identifying a community strength, not just its problems, but they all share the same DNA, assess, plan with the community, intervene and evaluate.

Okay, now we're going to do a quick history walk.

Section eight,

federal legislation.

This is the timeline of health planning in the U .S.

And understanding this context is so important because it explains why our health care system looks the way it does today.

You can see this pendulum swinging back and forth between regulation and competition.

We start way back in 1946 with the Hill -Burton Act.

The focus there was simple, bricks and mortar.

It was a massive federal aid program for hospital construction.

The result, we got a lot more hospital beds, but it only focused on the buildings, not on how care was actually delivered inside them.

Then we jumped to 1965, the regional medical programs.

The focus there was on technology, specifically for heart disease, cancer and stroke.

The result was some regional cooperation, but there were still huge gaps in care and a lot of duplication of services.

It was all about big science.

Then 1966 and 67, we get comprehensive health planning.

This was a big deal.

It was the first time there was a federal mandate for consumer involvement in health planning.

It created A, agencies at the state level and B, agencies at the local level.

It failed.

It failed spectacularly.

It had no funding and there was massive opposition from providers who did not want consumers telling them how to run their hospitals.

Then came the idea of the Certificate of Need, or CHI -HIM.

This concept is actually still around in many states.

The idea is that a hospital has to get government approval for major capital investments, like building a new wing or buying an expensive MRI machine.

It's an attempt to control costs by stopping an arms race for technology.

Then in 1974, we get the National Health Planning Resources Development Act.

The goal here was to combine the strength of all the previous acts to control costs and increase access.

It created things called health systems agencies, but it had a fatal flaw.

Which was?

It grandfathered the existing system.

So real structural change was basically impossible because the old inefficient system was protected by law.

And then the 1980s, the Reagan era.

A massive, massive shift.

The whole philosophy changed to competition and

federal funding for health planning was slashed.

And we moved towards systems like DRG's diagnosis related groups and HMOs to control costs.

It became a market driven system.

And that brings us finally to the Affordable Care Act, or ACA, in 2010.

Right.

And the ACA really put the focus back on the individual and the family.

It aimed for insurance for all, gave tax relief to small businesses, mandated that preventive care be covered 100 % and eliminated denials for pre -existing conditions.

And it has a strong focus on prevention.

A huge focus.

It aligns directly with the Healthy People 2020 goals by focusing on keeping people healthy in the first place, rather than just treating them after they get sick.

That brings us to our final comprehensive example that pulls all these ideas together.

Section 9, the case study of Jose Mendez.

This is a great one to end on.

It brings it all home.

So Jose is a bilingual student nurse and he's working with a Portuguese subsystem within a school.

His assessment was key.

He identified a lack of primary prevention,

basic hygiene, dental care, nutrition.

But his key diagnosis, his why, was really insightful.

It was.

He realized the problem was not a lack of concern from the parents.

It was a lack of knowledge.

The parents cared deeply.

They just didn't know the current standards for these things.

So for his planning, he used the concept of mutuality.

He collaborated with the teachers.

He set goals on multiple levels.

Right.

The individual goal was for the students to practice good habits.

The family goal was for the families to teach and reinforce those habits at home.

And the community goal was for the school to have systematic programs to provide this education long term.

And for his intervention, he was really smart.

He was.

He taught the children in both Portuguese and English.

And he sent summaries home to the parents in both languages.

And he included pictures for parents who might not be able to read well.

Brilliant.

Highly successful.

The resources were adequate.

The plan was culturally appropriate.

And it worked.

And the teachers were so impressed that they shared the success with state coordinators, which helped expand the scope of the project beyond that one school.

It's a perfect example of how a student project, when planned correctly,

can scale up and make a real difference, especially when it respects the culture of the community.

So let's wrap this all up.

Section 10, nursing implications.

What does all of this mean for the nurse who's listening to us today?

It means collaboration is absolutely key.

You can't do this alone.

And we need to be focused on those upstream interventions, fusing our knowledge of technology and health with a deep understanding of community needs.

And it means nurses have to be involved in policy.

We have to be.

We need to be on those planning councils, on those SION review boards.

We need to be the ones contacting our legislators and advocating for our communities.

We can't just be at the bedside anymore.

We have to be at the table where the big decisions are made.

Exactly.

Health planning is a core competency for baccalaureate nurses.

It requires applying the nursing process to the aggregate.

And systems theory is the framework that helps us do it.

Knowledge is most valuable when it's applied, whether it's a nerf like Maria starting an STD clinic or a student like Jose teaching hygiene or the student who got hired at the textile plant.

You have the power to change entire communities.

It's a huge responsibility, but it is absolutely where real lasting change happens.

That is a powerful place to leave it.

Thank you so much for joining us in this deep dive into community health planning.

Thank you.

It was a pleasure.

Thank you from the last minute lecture team.