Chapter 6 And 9 Study Guide Flashcards

Question

What is microeconomics?

Answer 1

-Microeconomic theory is concerned with supply and demand 1. Supply is the quantity of goods or services that providers are willing to sell at a particular price 2. Demand denotes the consumer's willingness to purchase goods or services at a specified price -In our free-market–driven economy, supply and demand is a key concept -Economists use microeconomic theory to study the supply of goods and services: how we, as consumers, allocate and distribute our resources, and how those marketing goods and services compete 1. They also examine how allocation and distribution affect consumer demand for these goods and services. -The concepts of supply and demand are influenced by each other and, in turn, affect prices -In health care economics, demand-side policies are enacted to reduce the demand for health care (e.g., raising insurance deductibles and copayments), and supply-side policies restrict the supply of resources (e.g., denial of coverage for specific services, utilization of preferred providers who practice within boundaries set by insurance companies, information overload for consumers) -Microeconomic theory is useful for understanding how prices are set and resources allocated 1. It comes into play when health care competition increases, because the success of the supply-and-demand concept depends upon a competitive market -Under the ACA, some traditional demand-side policies were removed to improve access to care 1. For example, preventive services must now be offered without deductibles or copayments, and insurance companies are limited in their ability to deny coverage for preexisting conditions

Answer 2

-Macroeconomic theory is concerned with the broad variables that affect the status of the economy as a whole, such as production, consumption, investment, international trade, inflation, recession, and unemployment on an aggregate level -The focus is on the big picture, or larger view of economic stability and growth, and it is useful for providing a global or aggregate perspective of the variables affecting the total economic picture and subsequent economic policy development -The economics of health care encompasses both microeconomics and macroeconomics and an intricate and complex set of interacting variables -Health care economics is concerned with supply and demand, as well as the big picture: 1. Are available resources sufficient to meet the demand by consumers and are the resources expended achieving the desired outcomes?

Answer 3

-How does a patient determine what services are needed, where to buy them, and how to evaluate the quality of the goods and services? 1. With health care, this is seldom the case; health care is typically unpredictable and often difficult to research 2. Even choosing a health insurance plan can be overwhelming considering the types of plans, the choices, the complexity, and one's level of health literacy -With health insurance companies and managed care, different prices are often paid for the same service, and consumers have little information as to the costs 1. Hence, health care purchases are not easily understood -In a free-market system, competition is an important factor, but is competition truly possible with employer-based or government health insurance that limits the choice of plans and providers? -Health care is an “opaque market” that keeps consumers in the dark about actual costs of services and medications due to confidential negotiations, discounts, and rebates 1. Market consolidation (e.g., hospitals that monopolize a geographic area, buy up competitors) allows them to bargain for higher compensation from health insurance companies 2. Consumers with health insurance are shielded from a typical business relationship with a provider or hospital *Costs have been the driver, not excess use of the health care system, and costs have risen faster than inflation since the mid-1960s 3. The multiple types of health insurance (variety of private companies and government plans like Medicare and Medicaid) in the United States lead to higher costs -Waste is another factor in our high cost of health care -Cutler estimated that as much as “one third of medical spending is wasteful,” and 25% to 50% of our health care dollar “is not associated with improved health” outcomes 1. When interventions are not clinically sound, that wasteful spending makes it more difficult to sustain preventive measures -Because traditional market forces of supply and demand work differently in health care, consumers are not solely responsible, as “government, insurers, employers, and providers themselves have a major role to play in controlling costs and ensuring access to care” 1. Some governments and employers have taken action to control costs -Consumers seek value and convenience in health care -There are, however, rare areas of health care where supply and demand works without any interference 1. These health care services are generally paid out-of-pocket, with direct interaction between the patient/consumer and the provider, as insurance does not cover them (cosmetic procedures are a good example) -Elective cosmetic procedures are an area where prices are more transparent because costs are paid by the consumer and not usually by insurers 1. Therefore, consumers are cost conscious and providers operate in a competitive marketplace with more transparent pricing 2. While elective procedures (e.g., cosmetic or LASIK surgery) demonstrate market influences, they are not typical of most health care expenditures *They also represent a select portion of the population—individuals who can afford them -Include health insurance concepts and employer-sponsored health insurance

Answer 4

-In 1963, economist Kenneth Arrow wrote an influential article about health care economics detailing the lack of information in the medical marketplace -The main points of the article still apply; Arrow noted that risk and uncertainty prohibit a true market economy in health care because consumers: 1. Do not know when or if they will become ill, but they know they will need and want medical treatment—thus the demand for health insurance 2. Do not know what services will be needed and what works best for their condition—thus the need for health care providers 3. Do not know about the quality of health care good and services—thus the need for government regulation (e.g., licensing, certification) and malpractice lawsuits 4. Are subject to an asymmetric level of information, compared to the insurer, about the likely demand for health care services *This can result in adverse selection (e.g., high-risk patients are denied insurance or care, smokers have higher health insurance premiums) and market failure (e.g., inefficiencies, lack of appropriate competition)—although this is less severe in large group insurance plans that spread out the risk

Answer 5

-Higher demand due to an aging population 1. The number of people over 65 is roughly 52 million (with 85.6% having one or more chronic health conditions) and is projected to almost double by 2060 -More people now have health insurance thanks to the ACA, estimated at about 20 million, and they have added to the demand -There is a projected physician shortage (about 90,000 doctors by 2025), just as demand for health care services skyrockets -Supply could be increased by hiring more nurse practitioners and increasing the number of medical residency slots available -Fully utilizing telemedicine would help extend care, especially into rural areas experiencing provider shortages

Answer 6

-People are generally risk averse, meaning that they do not like uncertainty, and this is seen often in relation to health care -Conventional economic theories hold that people will pay small premiums monthly to offset the risk of large medical bills should they become seriously ill 1. This represents an indemnity policy (much like car or homeowners' insurance), and this was the type of health insurance first offered in the United States 2. In the past, patients could choose any doctor or hospital and submit the providers' bills to the insurance company for payment -Moral hazard is the term used by economists to explain how health insurance changes the behavior of people, resulting in more risk-taking and wasteful actions 1. They liken it to fire insurance without a deductible, noting that a person may be less careful about clearing brush from a house or may even resort to arson if it costs the owner nothing to have the home replaced -If a person has health insurance, many economists hypothesize, they are less likely to take good care of themselves, and if they do not pay for their health care (through premiums, copayments, and deductibles), they are more likely to overuse it, although empirical evidence of this is sparse 1. In other words, economists theorize that insurance has a paradoxical effect and may lead to wasteful or risk-taking behaviors 2. In this scenario, patients will demand expensive health care, even if it provides only the smallest benefit 3. The concept of moral hazard is a driver for larger deductibles and copayments; these are used to control waste and overuse -A more recent viewpoint notes that consumers purchase health insurance not to avoid risk but to earn a claim for additional income (i.e., insurance paying for medical care) when they become ill and that copayments and managed care actually work against the system by reducing the amount of income transferred to ill persons or limiting their access to needed services -Moral hazard alone doesn't easily apply to health insurance because its effects may not be as predictable as in other instances of indemnity -Individuals who gain access to health insurance will use it, but there are still constraints (e.g., high deductibles, high copays) that moderate use and can be harmful to families who may have to choose between care for a sick child and rent or food 1. The case can surely be made that even those with unlimited insurance coverage don't just “check into the hospital because it's free” -Adverse selection, however, is a concern for health insurance companies when sick individuals seek insurance because they have an urgent need for health care, while healthy people do not want to buy it because they have no pressing health concerns 1. This imbalance is not cost-effective, yet a key feature of the ACA is for insurers to provide coverage for people with preexisting conditions (without charging them outrageous prices), which was formerly a common practice 2. This was initially balanced out by requiring that everyone get insurance -Cost sharing, which includes copayments and deductibles, divides the cost of health care services between insurance companies and patients 1. Insurance companies use cost sharing to prevent overuse of health services 2. The amount of a copayment or deductible may change for some types of care, such as a visit to the ED -Found that newer high-deductible health plans (HDHPs) not only reduced costs but also led to a reduction in office visits and preventive care -Balancing the cost reduction against the lack of preventive care (that could eventually lead to more cost savings) is an important consideration -Also, the effect of cost sharing on use of services is not equal 1. Individuals with low incomes decrease their use of medications and services more than those with higher incomes -The ACA limited cost sharing for people with low or moderate incomes, in plans offered by employers and plans purchased through the marketplace 1. For some people, the cost-sharing component of their health insurance is so high that they are considered underinsured 2. To be underinsured, one must have a deductible that is 5% of income or out-of-pocket costs in excess of 10% of income (not including premium costs) 3. Individuals and families often exhaust their savings, run up credit card debt, or else delay necessary medical care to avoid going into debt

Answer 7

-Employer-sponsored health insurance is the leading source of coverage for nonelderly U.S. citizens -A total of 49% of Americans had this type of insurance in 2017 -Medicare, Medicaid, and other government plans provided coverage to 36%, while 7% purchased policies directly from insurers -The flaws in this system were blatantly exposed during the COVID-19 pandemic, as millions of Americans filed for unemployment when businesses shutdown, causing them to lose access to health care 1. One example of the trickle-down effects of unemployment is the loss of reproductive health care for millions of women 2. Loss of access to contraceptive and preventive women's health care will place greater demands on publicly funded clinics that are continually underfunded and result in unplanned pregnancies or late diagnoses of cervical cancers and other health conditions -Historically, employers became the leading source of coverage because of three policy decisions in the 1940s and 1950s 1. During World War II, wage controls did not apply to health insurance, so employers used health insurance to lure workers from their competitors during wage freezes 2. The U.S. government determined that health insurance could be part of collective bargaining 3. In 1954, the IRS exempted health insurance premiums paid by employers from federal income tax -A 2019 annual survey revealed that 57% of all U.S. employers offered health insurance to their workers and 99% of large companies offered coverage 1. Small businesses may not offer employee health insurance because of the high cost and fewer employees -The percent of employers offering health insurance decreased somewhat after the ACA went into effect but increased in 2017; the first time an increase was noted since 2008 1. However, employers are continuing to pass along some of the higher costs of health insurance to employees in the form of higher employee premiums, deductibles, copayments, and stricter enrollment requirements -Those people whose employers do not offer health insurance coverage or who are self-employed can purchase nongroup health insurance 1. However, premiums are greater than the worker's share of employer group coverage 2. The ACA has made purchasing a nongroup policy easier and subsidizes the premiums for eligible people 3. Even in states that did not expand Medicaid, a greater number of people with lower incomes purchased insurance on the federal marketplace 4. Problematic changes in affordability and availability of ACA health plans, resulting in “churning and switching among enrollees,” have been noted 5. Variation in costs has not been eliminated with the ACA's community rating, but the variation is geographical; specifically, costs vary by location, not within one location -For persons earning incomes “at or below 400% of the federal poverty level” ($103,000 per year for a family of four), premium subsidies are provided for those purchasing on the insurance “marketplaces” 1. This keeps buyers from spending more than a “fixed percentage” of income (2.06% at the lowest level and 9.78% at the highest level) on health care premiums 2. Some “cost-sharing assistance” is available to subsidize private insurers, although it is only for those at lower income levels (100% to 250% of the federal poverty level, or $25,750 to $64,375) 3. It is expected that about 94% of potential costs for a “moderately generous” plan will be covered for those receiving this benefit -The cost of health insurance is a deterrent for many people. “In 2018, 45% of uninsured adults” stated that insurance costs were too high and that this was the reason they remained without it 1. Prior to the ACA, only 4% to 11% of those at the lower-income levels purchased nongroup health coverage 2. Although coverage levels generally increase as income rises, only 25% of those earning 10 times the poverty level purchased health insurance

Answer 8

-Known as Title XVIII of the Social Security Act Amendments of 1965, has provided mandatory federal health insurance since July 1, 1966, for adults aged 65 years and older who have paid into the Social Security system -It also covers certain people with disabilities (regardless of age) -Medicare is administered by the Centers for Medicare & Medicaid Services (CMS) of the USDHHS -In July 2019, Medicare covered more than 60.8 million people, the majority being aged 65 years or older (52.2 million), and paid health care costs of $618.7 billion -In 2018, 21% of total federal spending was for Medicare ($750.2 billion), and it is expected to increase 7.6% per year between 2019 and 2028 -Financing of Medicare is through general tax revenues (43%), payroll taxes (36%), premiums from beneficiaries (15%), and other sources -Out-of-pocket spending for Medicare beneficiaries was $5,460 in 2016, almost equally divided between medical/long-term care and premiums -Individuals with multiple chronic diseases and poor health spent more than their healthier counterparts -About 85% of beneficiaries were over the age of 65; the remaining beneficiaries qualified for Medicare 24 months after they became eligible for Social Security Disability Insurance (SSDI) 1. These recipients are younger than age 65 and permanently disabled or chronically ill, including those with end-stage renal disease -Although there are financial challenges facing Medicare and Social Security, both program trust funds have sufficient resources to pay full costs and benefits, without any adjustments, through 2035 1. The disability insurance trust fund will be intact till 2052 2. Reforms enacted with the ACA, and other actions, extended the life of these trust funds 3. Even after those funds have been spent, both programs can continue to pay 75% to about 90% of benefits using only their yearly tax revenues -There are four parts to Medicare: A, B, C, D

Answer 9

-Part A of Medicare, the hospital insurance program, covers inpatient hospitals, limited-skilled nursing facilities, home health, and hospice services to participants eligible for Social Security Disability Incom -The 2020 deductible per benefit period for inpatient hospitalization, including inpatient mental health, is $1,408 -Patients in a skilled nursing facility pay $176 per day after day 20 and assume all costs if care is needed longer than 100 days

Answer 10

-Part B of Medicare, the supplementary and voluntary medical insurance program, primarily covers necessary services to diagnosis or treat health issues and preventive services such as influenza vaccines -The 2020 annual deductible is $197, and recipients pay 20% of services once the deductible is met -No out-of-pocket charges are applied for annual wellness visits or preventive services that are rated “A” or “B” by the U.S. Preventive Services Task Force (USPSTF) -Monthly premiums vary depending on yearly income ranging from $144.60 to $491.60

Answer 11

-Part C Medicare plans, also called Medicare Advantage, are private plans subsidized by the federal government -Medicare Advantage plans are not supplemental to Part A and Part B—they take the place of Part A and Part B 1. Some may also cover vision, dental, and prescriptions -Unlike traditional Medicare, Part C plans use provider networks, which limit the choice of physicians or hospitals 1. They are regional, which may be problematic for seniors who want to spend winters in Florida and summers in Montana, for instance -Seniors can change their Part C plan during open enrollment periods or revert to traditional Medicare Part A and Part B 1. Other types of Medicare plans include Medicare Medical Savings Account (MSA) plans, Medicare cost plans, Programs of All-Inclusive Care for the Elderly (PACE), and Medication Therapy Management (MTM) program; these are not available in all areas -In 2018, over 14 million Medicare beneficiaries had supplemental coverage through a private company or employer retiree health insurance plans—known as Medigap coverage—added to Medicare Part A and Part B -Changes in Medigap coverage for new enrollees began at the start of 2020 -Part B deductibles are no longer covered under Medigap and Plans C and F are not allowed 1. However, these changes do not affect those enrolled prior to January 1, 2020 -People with Medigap coverage through their employers' retiree health plan generally pay lower premiums than people with coverage through a private company -With rising costs of health care coverage, companies are increasing premium costs for retirees, offering new options, such as Medicare Advantage to replace traditional health plans, or paying only a set amount for health coverage and leaving retirees to purchase their own insurance

Answer 12

-Part D is a volunteer prescription drug plan for those on Medicare or Medicare Advantage -The member can sign up for a Medicare Part D plan or an Advantage plan with medication coverage -Costs vary based on state of residence -Plans differ in coverage, so clients should be encouraged to research the plans to determine if their medications are included in the plan's formulary

Answer 13

-Known as Title XIX of the Social Security Amendments Act of 1965, provides medical assistance for children, pregnant women, parents with dependent children, seniors, and people with severe disabilities -Medicaid is an optional program for states, but all states currently participate -Over time, the scope of Medicaid increased, and states opting to provide Medicaid were required to implement each increase—or lose their federal Medicaid funding -As the importance of social determinants of health gains wider acceptance, more states are requiring Medicaid managed care organizations (MCOs) to screen for determinants and provide social services, such as housing and nutrition assistance -Because Medicaid covers so many people, many of whom have complex health needs, it represents a significant proportion of health care spending in the United States -Prior to the ACA, childless adults without disabilities were not eligible for Medicaid 1. Under the ACA, Medicaid was expanded to all nonelderly adults with incomes up to 138% of the FPL, or $17,236 for an individual in 2019 -Other changes made through the ACA were to extend Medicaid coverage for children in foster care until age 26—equal to the requirement that private plans allow dependent children to remain on a parent's plan until that age 1. States also needed to make the Medicaid application process easier -Medicaid is jointly funded between federal and state governments to assist the states in providing adequate medical care to eligible persons -The federal government matches state Medicaid spending, and this is the largest source of federal funding for states 1. The federal government pays a portion of the costs, called the Federal Medical Assistance Percentage (FMAP), at 50% to 76% -The funding model for Medicaid has both benefits and problems 1. There isn't a limit on federal spending, so as states expand their Medicaid programs, more federal funding flows to states 2. This allows Medicaid to expand during epidemics or pandemics (e.g., COVID-19), natural or man-made disasters, or short economic downturns 3. At the same time, when the economy contracts, as in the 2008 recession, many more people become eligible for Medicaid at a time when state and federal funds were decreasing -The states have some discretion in determining which population groups their Medicaid programs cover and the financial criteria for Medicaid eligibility, as well as the scope of services, rate of payment, and how the program will be administered, so long as they meet the minimum requirements set by the federal government -Medicaid is also a source of innovation in health care 1. States implemented medical homes, care coordination, integration of physical and mental health care, and other “new” services earlier than private health plans 2. The flexibility built into the federal requirements for Medicaid, Medicaid rule waivers to test ideas, and the new Innovation Center in CMS (part of the ACA) allow states to develop new models of health care delivery -Patient advocates (e.g., physicians, nurses, community leaders) often express concerns that many Medicaid managed care plans (or state administrators) are more focused on keeping their costs down than on improving patient care 1. The system has wide variability in cost-effectiveness and quality 2. Ensuring access and quality of care in a managed care environment will require fiscally solvent plans, established provider networks, and awareness of the unique needs of the Medicaid population 3. Also, both providers and beneficiaries need more education about managed care -Although there are access and quality problems with Medicaid, one large study examining differences between an uninsured population and those with Medicaid found that patients with Medicaid were more likely to see a physician at least once annually 1. Among low-income populations with high blood pressure, those with Medicaid had greater awareness and control of hypertension, although this was not the case for those with high cholesterol or diabetes

Answer 14

-The ACA initially required all states to expand Medicaid -This was legally challenged by several states, leading to a Supreme Court case—National Federation of Independent Business v. Sebelius -The Medicaid expansion was ruled to be unconstitutional because it was highly coercive and the Medicaid expansion became optional for states -Currently, 37 states have expanded Medicaid coverage 1. However, a gap in coverage exists in states choosing not to expand Medicaid coverage; Medicaid eligibility is 40% of the federal poverty level ($8,532 for a family of three in 2019) -According to the Center on Budget and Policy Priorities (CPPB), since expanded Medicaid coverage was implemented, over 19,00 lives have been saved 1. Whereas, in states that have not expanded Medicaid, roughly 15,500 lives have been lost -The largest portion of Medicaid spending goes toward people with disabilities (40%) and older adults (21%), but these two groups comprise only 23% of Medicaid enrollees

Answer 15

-Outpatient and inpatient hospital services -Early childhood screenings and well-child checkups (to age 21) -Physician and nurse practitioner/certified nurse midwife services -Lab and x-ray services -Family planning services -Tobacco cessation counseling for pregnant women -Home health care and nursing home services for those over age 21 (including rehabilitation centers) -Federally qualified health center and rural health clinic services -Transportation to medical care

Answer 16

-A key factor to Medicaid's future success is reimbursements to providers, both the amount of payments and administrative delays 1. Medicaid has historically reimbursed providers at a lower rate than Medicare, and other insurance programs and filing for reimbursement can be onerous -In 2016, Medicaid fees paid were an average of 72% of those paid by Medicare 1. In states where the fee ratio was above the median, physicians accepted Medicaid patients at higher rates than for those below the median 2. This is problematic for C/PHNs who may have difficulty finding a health provider for clients -States may also take a long time to make the reimbursement payment 1. These issues create burdens for clinics and private physician offices, leading to a lack of provider participation—and a lack of access to care for enrollees -When state resources are strained, provider reimbursement rates are often cut 1. This leads to fewer providers willing to take Medicaid patients—it is estimated that about 30% of physicians in the United States will not accept Medicaid patients -Despite these issues, Medicaid provides societal benefits 1. Medicaid coverage is associated with reduced rates of infant mortality, especially in African American infants -In addition, providing coverage to children early in life leads to higher educational achievement, higher income, and decreased use of public programs

Answer 17

-Reimbursement for health care services generally has been accomplished through one of two approaches: retrospective or prospective payment -A traditional form of reimbursement for any kind of service, including health care, is retrospective payment, which is reimbursement for a service after it has been rendered -A fee may or may not be established in advance 1. However, payment of that fee occurs after the fact, or retrospectively, termed fee-for-service (FFS) -In health care, limited accountability in the use of retrospective payment has created several problems 1. With third-party payers (e.g., insurance companies, the government) serving as intermediaries, neither consumers nor providers of health services were accountable for containing costs 2. As more advanced technology and new medications became available, costs increased. 3. Third-party reimbursement also increased, along with other factors, to create an inflationary spiral of escalating costs 4. FFS promoted sickness care rather than wellness services 5. Providers were rewarded financially for treating illness and for providing additional tests and services 6. There were few incentives for prevention or health promotion -Although retrospective payment worked well in other industries, from a cost-containment as well as a public health perspective, it has not worked well in health care and is now rarely used

Answer 18

-Prospective reimbursement, although not a new concept, was implemented for inpatient Medicare services in 1983, in response to the health care system's desperate need for cost containment 1. It has since influenced the Medicaid program, as well as private health insurers -The prospective payment form of reimbursement has virtually eliminated the retrospective payment system -Prospective payment is a payment method based on rates derived from predictions of annual service costs that are set in advance of service delivery -Providers receive payment for services according to these fixed rates, set in advance 1. Payments may be in the form of premiums paid before receipt of service or in response to fixed-rate (not cost) charges -To correct unlimited reimbursement patterns and counteract disincentives to contain costs, prospective payment involves four classic steps: 1. An external authority is empowered (by statute, market power, or voluntary compliance by providers) to set provider charges, third-party payment rates, or both 2. Rates are set in advance of the prospective year during which they will apply and are considered fixed for the year (except for major, uncontrollable occurrences) *The provider accepts the assignment of fees 3. Patients, third-party payers, or both pay the prospective rates rather than the costs incurred by providers during the year (or charges adjusted to cover these costs) 4. Providers are at risk for losses or surpluses -Prospective payment imposes constraints on spending and provides incentives for cutting costs 1. The federal government enacted a prospective payment plan (The Social Security Amendments Act of 1983)

Answer 19

-The plan is a billing classification system known as diagnosis-related groups (DRGs) 1. The system is based on about 500 diagnosis and procedure groups 2. It provides fixed Medicare reimbursement to hospitals based on weighted formulas 3. Flat rates of payment are based on average national costs for a specific group, adjusted annually, with some regional variations accounting for higher wages and other costs -This system was enacted to curb Medicare spending in hospitals and to extend the program's solvency period 1. It was designed to create incentives for hospitals to be more efficient in delivering services -The prospective payment system reduced Medicare's rate of increase for inpatient hospital spending and increased hospital productivity by reducing hospital stays and unnecessary admissions, according to Clifton and Rambur -The system, however, led to DRG creep or “upcoding” (i.e., classifying patients into more lucrative categories) and patient dumping (i.e., transferring patients whose reimbursement is expected to be lower than actual costs of services) in an effort to counteract the losses in revenue and in some circumstances make hefty profits 1. The CEO of Prime Health Services and 14 of the company's hospitals settled a $65 million settlement for “upcoding,” a practice in which patients are assigned a DRG requiring a higher level of care than what the patient needs

Answer 20

-Cost inflation was addressed by DRGs and other measures; CMS has mechanisms in place to investigate fraud or abuse -Quality was addressed in October 2008, when Medicare began withholding payments to hospitals for preventable errors in an effort to provide an incentive to prevent avoidable mistakes and improve patient care 1. There are 29 preventable errors (often called “never events”) grouped into 7 categories -Appropriate mechanisms must be in place to provide accountability and take action when needed—as when billing and other fraud is prosecuted 1. Cutler estimated that overall health care fraud for public and private payers may be as high as 10% of total costs -These changes were instituted at the request of Congress, and initially, many hospitals complained that their payments would be substantially reduced, especially for complicated patients

Answer 21

-Never events” are medical errors or adverse events that never should happen and are largely preventable -An expanded list of 24 never events for hospitals—serious incidents that could have been prevented—was approved for nonpayment by Medicaid beginning in July 2012 for all states -The goal was to reduce serious medical errors and preventable infections that should reduce costs and improve patient care -Progress toward this goal of improved quality of care is evident by saving the lives of 8,000 people and saving close to $3 billion 1. However, never events still occur -Medical errors account for 100,00 deaths and costs 20 billion a year 1. In addition, there are 4,000 surgical errors reported yearly -The ACA includes incentive payments to primary care providers who meet quality goals 1. Nursing instituted the QSEN initiative -Debate continues about nonpayment outside of hospital settings and about which conditions should be included in the list of never events

Answer 22

-Spread of disease via travel -Bubonic plague (Black Death), beginning in mid-1300s -Health, social, and sanitary reforms

Answer 23

-Colonial times -Pre-1800s -1800s 1. Scientific advances: germ theory, sterilization 2. Improved sanitation, working conditions 3. Creation of federal quarantine system

Answer 24

-1929: Baylor U Hospital provides prepayment plans 1. Physicians develop similar plans -1965: Medicare and Medicaid -2010: Patient Protection and Affordable Care Act (ACA)

Answer 25

-Benefit from investors’ funds -Pay investors a portion of money they earn

Answer 26

-Example: World Health Organization 1. An agency of the United Nations 2. Formed in 1948 3. Has 194 member nations -Functions 1. Focus on issues of global concern 2. Set policy 3. Monitor health conditions and programs

Answer 27

-Sheppard-Towner Maternity and Infancy Act of 1921 -Hill-Burton Hospital Survey and Construction Act of 1946 -Social Security Act Amendments of 1965 -Medicare Modernization Act of 2003 -Patient Protection and Affordable Care Act of 2010

Answer 28

-Third-party payments -Direct consumer reimbursement or out-of-pocket payment -Private and philanthropic support -Third-party payments 1. Private insurance companies (trend toward health savings accounts) 2. Government health programs *Medicare, Medicaid, Supplemental Security Income, Social Security Disability Insurance

Answer 29

-Retrospective -Prospective -Surprise medical billing 1. Individual unaware of provider not being in-network -Capitation -Claims payment agents (e.g., Blue Cross/Blue Shield)

Answer 30

-High cost of health care in the United States -Access to health services -Medical bankruptcies -Managed care

Answer 31

-Allocation of fixed or limited health care resources -Social justice view 1. Health care as a right 2. Not based on income or where one lives -Free market economy view 1. Health care as a product 2. Concern over decline in quality, increased waiting

Answer 32

-Managed competition -Universal coverage and single-payer system 1. Pros: universal coverage; administrative simplicity; combination of private/public; no tie to employment 2. Cons: removal of competition model, which ensures a free market, individualism, and the right to choose

Answer 33

-Disincentives for efficient use of resources -Incentives for illness care -Conflicts with public health values

Answer 34

-Need to adapt to constantly changing system -Variety of practice settings -Development of skills in teamwork, leadership, and political activism -Recognition of importance of outcomes

Answer 35

-Built environment -Climate change -Land use -Toxic exposures -Toxic waste -Radiation

Answer 36

-The built environment refers to all aspects of our environment that are not naturally occurring and includes not only the physical structures (e.g., homes, schools, workplaces, dams, roadways, buildings, energy sources) but also the features that contribute to social cohesiveness or disruption -The impact of the built environment includes indoor and outdoor physical environments, which in turn affect the social environments where people live, work, and engage with others -Considering that Americans spend upwards of 90% of their time indoors, our built environment can have significant impact on our health -In recent years, there has been a shift in community development to consider the influence of the built environment on community health and cohesion 1. Evidence suggests that many physical and mental health problems are related to the built environment, such as asthma, cardiovascular disease, lung conditions, obesity, and cancer 2. Increasingly, communities are promoting social engagement and human health in the built environment by improving public transportation, promoting areas for walking and biking, enhancing green spaces, and addressing sustainable energy sources -Many U.S. cities are addressing issues related to community/public health and the built environment by implementing the UN SDGs 1. The UN Sustainable Development Solutions Network ranks U.S. cities in meeting the SDGs, which serves as an indication of impacts of the built environment on community health -Another C/PHN role is to assess the quality of the housing 1. Buildings that were constructed prior to 1978 are likely to have lead-based paint, and homes built before 1987 may have lead soldering in the plumbing that delivers household drinking water 2. Homes or buildings constructed between 1930 and 1950 are likely to have asbestos in the insulation, as well as in the hot water and steam pipes -The overall condition of the community indicates sanitation factors, safe waste disposal, and potential sources of contamination -The location of schools, playgrounds, and public transportation and access to green spaces should be part of the community assessment -Examination of the overall community environment provides C/PHNs with essential information about how the environment is likely to impact the residents' health

Answer 37

-Climate change is our greatest global public health threat -Climate change “refers to significant changes in global temperature, precipitation, wind patterns and other measures of climate that occur over several decades or longer” -Unfortunately, in the United States, instead of addressing the realities of climate change, it has become politicized, leading to inaction and avoidance of our very serious reality 1. For example, the U.S. EPA has removed most of the documents concerning climate change and its impact on human health from its Web site, and, in 2017, President Trump withdrew the United States from the Paris Climate Agreement -The Paris Agreement is an international agreement of signatory countries to limit greenhouse gas emissions in an effort to keep temperature rise below 2°C of preindustrial temperatures and to target temperature reduction to 1.5°C 1. The target of 1.5°C preindustrial temperatures has been further supported by a sobering report from the Intergovernmental Panel on Climate Change, in which the world's leading climate scientist stated that to avoid severe impacts of climate change, the world must reduce carbon emissions by 45% now -Temperature changes affect weather patterns that can result in more frequent extreme weather events, disease outbreaks, food and water shortages, and changing migration patterns -Nurses are in a position to take a lead in addressing climate change through individual, professional, local, and national mitigation, adaptation, and resilience strategies -When assessing communities, the nurse should note vulnerable groups such as pregnant women, infants, children, older adults, people with disabilities, non-English speakers, and the poor -In addition, communities may experience risks related to food and water quality and availability, heat stress for those most vulnerable, increased air pollution, and severe weather-related events 1. Severe weather events such as flooding, droughts, hurricanes, and tornados require emergency preparedness and disaster response from the public health sector -Specifically, C/PHNs must be prepared for surge events by developing skills such as the ability to (1) be personally prepared, (2) comprehend state and local disaster plans, (3) conduct a rapid needs assessment, (4) investigate outbreaks, (5) perform public health triages, (6) communicate risk effectively, (7) participate effectively in mass dispensing interventions, and (8) respond after the event to the debriefing and public health impact of the event, as outlined in a seminal article by Polivka et al -Nurses need to be prepared for inadequate resources and infrastructure, as well as the lack of electricity and technology -Nurse leaders are disseminating timely and accurate information for nursing practice through resources and collaboration with national organizations 1. All nurses must understand the implications of climate change on health. -Together with nine other organizations, including the National Student Nurses' Association and the Public Health Nursing Section of the American Public Health Association, the ANHE established the Nursing Collaborative for Climate Change and Health to bring leaders and institutions together to advance climate solutions to protect the health of Americans -In addition, ANHE has cooperated with Health Care Without Harm to offer the Nurses Climate Challenge 1. This project educates practicing nurses about the health impacts of climate change so that they, in turn, can educate their nurse colleagues about climate health 2. Another valuable resource for nurses is the U.S. Global Change Research Program report, Forth National Climate Assessment

Answer 38

-Topics that must be considered when conducting community health assessment to address land use include zoning regulations and enforcement, industries and their toxic releases, types of transportation, sidewalks, bikeways, public transportation, recreational space including green space, what fertilizers or pesticides are applied to the fields, safe play areas for children, and information regarding a tree ordinance to promote health environments -School locations should be examined for accessibility by foot or bicycle, the safety of the surrounding area, and the use of pesticides on school fields -The community should be assessed for commercial lots, their safety and use, and vacant lots or unused property 1. Specific commercial businesses such as gas stations, auto repair shops, and dry cleaners are often common sources of toxic exposures -If the community has agricultural areas, these must be assessed for irrigation practices, use of pesticides, runoff, and land use practices 1. In addition, waste can be a source of environmental hazards -C/PHNs must assess for the presence of landfills or municipal waste incinerators, medical waste incinerators, and municipal trash collection or dumpsters throughout the community -Land use and transportation patterns and plans can influence the health of the community 1. The design of a city, community, or neighborhood affects physical activity, automobile dependence, ability of those of older age and those with physical disabilities to navigate the community, and opportunities for children to walk to school 2. Community design also highlights concerns for environmental justice when those who live in areas of low accessibility and high exposure to pollution are more likely to be of minority status or living in poverty -As communities transition to sustainable practices with more walking and biking areas, considerations should be made to reduce environmental risks for walkers and bikers in areas of high vehicular traffic

Answer 39

-Walking as an indicator of community health -Physical activity levels and contributory factors -The public health consequences of public safety design choices -The types and determinants of travel to school -The influence of community design on risk of injury -The influence of community design on emissions of overall and specific pollutants -Physical activity, mobility, and social integration in persons with disabilities -Social equity and health outcomes in relation to community design -The influence of physical setting characteristics on mental health -The impact of community engagement on environmental health

Answer 40

-Air -Water -Food

Answer 41

-Air quality is a major variable in the health of populations -People living in areas that have poor air quality experience higher rates of disease and adverse health effects -Climate change contributes to air pollution and adversely affects health -Ambient air, or outdoor air, can be affected by a number of air pollutants -Air pollution is composed of a variety of materials such as aerosols, criteria air pollutants (carbon monoxide, lead, ground-level ozone, nitrogen dioxide, sulfur dioxide, particulate matter), VOCs, and hydrofluorocarbons, as well as radon and other gases that contain harmful toxins -Our health is influenced by the air we breathe both indoors and outdoors -Ambient air is composed of gases such as nitrogen, oxygen, argon, carbon dioxide, hydrogen, neon, helium, and other gases, which are part of the atmosphere 1. It also contains moisture and particulate matter 2. The amount of hazardous material that is contained in ambient air is the reason that the Clean Air Act of 1970 was created -C/PHNs must understand the adverse effects of ambient air pollution to assess, monitor, and advocate for those most vulnerable, which includes children, people with lung disease, older adults, and even healthy individuals who are active outdoors -Health effects include irritation of the respiratory system with inflammation of the cell lining 1. This makes the lungs more susceptible to infection 2. Air pollution can also exacerbate asthma and cause chronic lung disease, reduced lung function, and lead to permanent lung damage 3. In addition, air pollution causes increased risk of cardiac disease, in particular acute myocardial infarctions and arrhythmias

Answer 42

-In response to the Clean Air Act of 1970, air quality is monitored by the EPA -In an effort to inform citizens about the air quality in their own communities, the EPA created the Air Quality Index (AQI), which is often reported in media sources on a daily basis -The AQI is calculated for four of the six criteria air pollutants (ground-level ozone, particle pollution, carbon monoxide, and sulfur dioxide) to see if they exceed the national air quality standard set by the EPA, with an emphasis on their effect on health -Reports from the EPA monitoring of air pollution indicate that from 2010 to 2017, the overall levels of the six major pollutants measured by the federal government (carbon monoxide, ozone, sulfur dioxide, nitrogen dioxide, lead, and particulate matter) declined by a high of 80% for lead and a low of 5% for ozone because of cleaner cars, industries, and consumer products 1. However, millions of people live in areas that exceeded the national ambient air quality standard (NAAQS) set by the EPA

Answer 43

-Indoor air quality is particularly important for home, school, and workplace assessments -When the AQI for outside air is high, in order to avoid pollutants, people are instructed to stay inside 1. However, indoor air quality may be poor and expose people to pollutants, microbials, and particulates that may also lead to adverse health conditions -Air pollution in homes occurs from exposure to heating or combustion sources such as oil, coal, kerosene or wood, radon gas, secondhand smoke from cigarettes, building materials and furniture that contains pressed wood products, carpeting and adhesives that emit VOCs, asbestos in insulation, cleaning products, paints, varnishes, and paint removers, personal care products, and other sources used around the home such as pesticides -Mild health effects might be headaches and nausea; the more serious health effects include damage to the liver, kidneys, and central nervous system, as well as cancer 1. In addition, molds, dust, and known asthma triggers in the home can not only exacerbate asthma symptoms but also cause irritation to those with heart and lung conditions -Air quality in school buildings is very important for staff, teachers, and students 1. More than 56 million children and adults spend up to 6 to 8 hours in elementary and secondary school each day 2. In particular, children are at increased risk for a variety of reasons -Young children are more likely to spend time on or near the floor where toxins are likely to settle; they use more hand-to-mouth behavior, and they take in more air per size than adults -Although exposures can be the same as in the home, those who attend or work in schools are in the same air environment for 6 to 8 hours or more where they are exposed to the toxins for long periods of time -Nurses who work in the school setting can access information through the EPA Web site to aid in assessments and interventions to improve air quality in schools

Answer 44

-In public health, the concern is for safe water consumption; safe lakes, rivers, and streams for recreation; and safe waterways to support animal and plant life necessary for transport of nutrients and ecology of the environment -The availability of clean water is becoming a very serious threat to human survival -Globally, 2.1 billion people lack access to safe water, and in 2017, approximately 4.5 billion did not have access to an improved sanitation facility creating threats to safe water -Poverty is linked with lack of access to clean water and sanitation 1. Every day, approximately 1,000 children die from a water and sanitation-related diarrheal disease -The critical importance of this issue is born out by the UN including water and sanitation as one of its SDGs -Drinking water is available in two forms: surface water and groundwater 1. Both are potential sources of contamination or pollution 2. Surface water sources include lakes, streams, and municipal reservoirs for water use 3. Underground sources, or groundwater, include aquifers that run beneath the ground level and are reached via wells and springs -Many municipalities use reservoirs and other surface sources for their water supply, whereas in many areas, people must rely upon wells to provide their source of water -Safe drinking water is essential for human health 1. Public water systems provide water for community members 2. Public water systems are monitored and regulated through the EPA 3. These regulations require that public water suppliers protect consumers from microorganisms and contaminants that are harmful to health -The EPA does not regulate private sources of water from private wells 1. The individual users must be responsible for monitoring their own wells 2. Private well owners should test their water annually and anytime there is a risk of contamination such as flooding, repair to the well system, changes in water quality, or local construction -Water can become contaminated from a number of sources, including point and nonpoint sources -To rid public water systems of microorganisms, disinfection processes are used 1. Disinfectants that are chlorine based can produce by-products that can also be hazardous to health 2. Additionally, other inorganic (such as nitrogen derivatives, arsenic, lead, fluoride, cadmium, and mercury) and organic chemicals (commonly organophosphates, phthalates), as well as radionuclides, are frequent water contaminants -Not only are pharmaceuticals used by humans, excreted in their urine, and discarded into locations where they can reach water supplies but also animals are fed with hormones and antibiotics in animal feeding operations that can leach into water supplies -C/PHNs must be aware of sources of water contamination that puts vulnerable population groups such as the growing fetus, infants and children, older adults, and those with compromised immunity at great risk 1. Organizations such as Health Care Without Harm seek to address the pharmaceutical waste issue through measures that address production, use, discharge, and disposal, treatment in wastewater facilities, and collection of unused medications -The Right to Know legislation and use of Safety Data Sheets provide some assurance and can be helpful in teaching our clients how to better protect themselves as well -Nurses can teach their community partners how to access a consumer confidence report 1. Every public water system is required to provide information to consumers that identify any detected contaminants or factors that affect the water quality for those customers that they serve 2. This responsibility to provide the public with information about public water systems is mandated through the SDWA enacted in 1974 that established standards for safe drinking water 3. Individuals can access information from their own water supplier or can visit the EPA Web site -A risk to community water supplies occurs in the communities where unconventional natural gas or oil extraction, also known as fracking, occurs

Answer 45

Those that can be traced to one source, such as a wastewater facility release into municipal water or discharge from an industrial site

Answer 46

-Runoff from agricultural area, gasoline stations, and other contaminants carried by rain and waterways -Some common water contaminants are microbial (frequently Cryptosporidium and Giardia)

Answer 47

-This is a process to extract natural gas or oil from deep underground for public use -Fracking has the potential to contaminate air and water from chemical sources such as methane, benzene, and other hydrocarbons, and it poses health risks to community members as well as the workers involved in extraction operations -Fracking is occurring throughout the United States 1. In fact, 21 states permit fracking, including Arkansas, California, Colorado, Pennsylvania, Texas, and Wyoming -Methane, benzene, and other chemicals have been found in the groundwater in communities where fracking takes place -Health concerns, such as respiratory and nervous system problems, along with blood disorders, cancers, and birth defects, have been noted -It is important to remember that process of fracking and health risk is not only related to exposures from the well sites but the entire process from well preparation to delivering the fuel to the marketplace, sometimes across state lines where gas or oil extraction is not permitted

Answer 48

-Food quality, quantity, and safety are essential to human health -Food quality refers to the relative nutritional value, cost, and variety of food available 1. The CDC estimates that each year more than 3,000 people die from foodborne illness and 1 in 6 Americans becomes ill from food consumption -C/PHNs frequently work closely with environmental sanitarians in state and local health departments who routinely monitor food establishments for their safety to prevent exposure to microbial agents that cause foodborne illness Environmental issues that affect food quality extend beyond the microbial exposures and include the availability of adequate nutritious food, chemical exposures through food additives and from agrichemicals and antibiotics, contaminated food from diseased animals, and improper food handling -Pesticides are ubiquitous in the environment and are transmitted to humans through foods 1. Fresh fruits and vegetables must be thoroughly washed to remove pesticide residue 2. In addition, antibiotics fed to animals in animal feeding operations are transmitted through this food -After production, many foods are processed for market 1. Food additives such as dyes and flavors provide the color and often improve flavor of foods 2. Leavening and thickening agents improve consistency, while preservatives keep food from spoiling on the shelf 3. Many of these additives can be harmful to health with examples being linked to cancer and endocrine disruption -Recently, there is a concern about genetically modified foods being marketed 1. These concerns not only address the safety of the food for human consumption but also raise questions about the ecological impact and sustainability -Microbial outbreaks are common from a variety of bacteria (Shigella, Salmonella, Campylobacter, Escherichia coli) and parasites (Cryptosporidium parvum, Amoeba) 1. FDC, state and local authorities, and CDC joined to investigate food contamination outbreaks, isolate the cause, and inform health professionals and the public -Although the public often hears about these outbreaks through the media, they may not be as aware of the risks from chemical contaminants 1. A great resource for families and community members is the Partnership for Food Safety Education that promotes safe food handling and education for both children and adults -The U.S. Food and Drug Administration (FDA) is charged with the responsibility to ensure the safety of food produced, shipped, imported, and sold in the United States 1. This includes the monitoring of microbial toxins and chemicals such as lead and cadmium, pesticides, food additives, and packaging -Although the FDA operates to ensure that the genetically modified foods meet the same safety standards as other foods, the technology used to modify or engineer new food varieties from plant and animal breeding techniques is expanding rapidly -Fish and other seafood are an important part of food safety 1. Nurses should be aware and instruct communities to monitor fish advisories 2. The advisories warn consumers of contaminants (mercury, PCBs, chlordane, dioxins, and DDT) 3. These contaminants persist in the environment, particularly in river and lake sediments where fish consume them from bottom-feeding organisms

Answer 49

-Bioaccumulation refers to the process where toxins accumulate in greater concentration in an organism than the rate of elimination -Toxins can accumulate from direct exposure or from eating contaminated food products -Through biomagnification, the toxins present at lower levels of the food chain are in greater concentration in those species further up the chain -Therefore, humans who eat contaminated fish are exposed to toxins at all levels across the food chain

Answer 50

-C/PHNs must also be aware of the increased vulnerability of certain groups 1. For example, pregnant women are likely to transmit their exposure to chemicals, pesticides, and toxins to the unborn fetus, children are more susceptible to hazards from food because of their immature gastrointestinal systems and increased food intake per size compared to adults, and those with altered immunity due to cancer, diabetes, and other health conditions are more likely to be affected by food exposures -Nurses can be a resource to ensure that community members learn about the specific local risks and identify ways to decrease their risk -The Pesticide Action Network uses data from the USDA Pesticide Program to identify commonly applied pesticides for many foods 1. Consumers can consult their Web site to be informed of foods that pose the most serious threats to health, particularly for the most vulnerable groups -In addition, the effect of climate change on weather extremes (droughts, foods, and storms), changes in rainfall and water supply for soil, rising atmospheric greenhouse gases, and the ecology of microbial growth will have negative impacts upon the food supply 1. Extreme weather events increase the likelihood of chemical contaminants and pesticide exposures from runoff that occurs with flooding -Agriculture and fisheries industries are sensitive to specific climate conditions related to changes in temperature and levels of CO2 in the atmosphere 1. Additionally, our changing climate has led to loss of nutritional content and impact on water resources and crop production -Globally, these changes can also affect human health 1. Scientists report the risks for waterborne and foodborne pathogens in drinking water, seafood, and fresh produce from climate variability and the potential for ecological changes that can affect watershed and drainage

Answer 51

-Individuals, families, schools, governmental agencies, health care facilities, and industries all create waste that must be managed to minimize environmental impact and to protect human health -In an effort to minimize waste and environmental impact, local, state, and federal agencies have begun supporting sustainable practices that highlight the environmental value of reducing and reusing products -The EPA offers a waste management hierarchy that highlights the value of reducing and reusing materials as a priority and recycling is the second level, when the items are not able to be reused -In particular, our use of plastics and its ecological impact on sea life highlights the importance of reducing and reusing products -The waste management hierarchy offers an upstream approach of reducing waste at the source of waste generation 1. For health care facilities, this can mean environmentally preferred purchasing of products that are less toxic, contain recycled materials, more energy efficient, and are safer and healthier for patients, health care workers, and the environment -Although efforts are made to reduce health risk, hazardous wastes continue to be produced 1. These wastes include solvent wastes, dioxins, and wastes from electroplating and other metal finishing operations, wastes from oil refineries, organic chemicals, pesticides, explosives, lead processing materials, and wood preservatives 2. We are exposed to these chemicals if they are aerosolized into the ambient air, leach into ground or wells, and reach the soil where children play, or crops are produced 3. What is particularly dangerous for human exposure is the fact that most community members are unaware of the hazards in their communities -Communities may be burdened with many brownfield sites, as well as those listed on the National Priorities List of hazardous sites as Superfund sites -Popular media such as books, films, newspapers, television, and social media may be the first place that nurses become aware of communities affected by toxic waste -Nurses should be knowledgeable about the toxic hazards in their own communities and those where the patients and families they care for reside -Through the EPA Superfund Web site, nurses can assist community members in learning about Superfund sites that impact their communities -Further, on the EPA Brownfields Web site, nurses and community members can learn about Brownfields Near You -It is important for the nurse to be alert for reports of toxic exposure risk, evaluate the science and toxicological risk, and advocate for community/public health

Answer 52

-Humans are exposed to radiation in a variety of forms -Risks and forms of radiation are generally categorized as ionizing and nonionizing radiation -Ionization refers to the process where the atomic particle (ion) breaks away from the nucleus of the atom -Ionizing radiation occurs in natural forms as radon gas and cosmic radiation from the atmosphere -Nonionizing radiation refers to radiation from sources such as infrared, microwave, and radio wave radiation -Radon is an odorless, ionizing, radioactive gas. Radon can seep into the foundation of homes from the ground and expose residents to the radiation effects 1. Radon exposure is a leading cause of lung cancer -Nurses must be aware of areas with high radon risk and should be sure that community members are educated about the risks of radon

Answer 53

-C/PHNs incorporate an “upstream” focus into their work with populations -This approach emerged from the seminal publication by John McKinley in 1979, A Case for Focusing Upstream, which identified root causes of disease and the multiple factors that lead to illness -The C/PHN approach to prevention and health promotion relies on an upstream approach to address the root causes that influence health at the institutional and system level rather than looking solely at healthy lifestyle issues; in other words, C/PHN direct their care “upstream” from the identified problem or issue -Two related concepts for environmental health nursing associated with upstream focus are health disparities and the social determinants of health 1. This focus for public health and environmental health nursing was introduced in a classic article by Butterfield, who reminds the nursing profession that nurses, particularly C/PHNs, serve to reduce risks -C/PHNs are often the “sentinels of surveillance”, who detect unusual illness patterns and respond to environmental emergencies in work and community settings -With emphasis on data it is estimated that as much as 33% of disease occurrence is attributable to environmental exposures and that the prevalence of environmentally linked health problems such as asthma, neurological problems, certain cancers, and birth defects are all on the rise, a case can be made for nurses to use an upstream framework to assess, monitor, educate, advocate, and create policies to reduce environmental health risks

Answer 54

-For example, a C/PHN is taking an upstream approach to asthma prevention by working with legislators to strengthen ambient air quality polices -Thus, the nurse is moving up along the system to address a leading factor, outdoor air pollution that causes asthma

Answer 55

-Dr. Butterfield's original work, the Butterfield Upstream Model for Population Health (BUMP), applies an upstream public health nursing approach to environmental risks by giving nurses the framework to address the determinants of health and health inequities that influence health outcomes across the life course of a population -Specific points that are part of the BUMP framework are: 1. Assessing and analyzing the environmental exposures for the community or population 2. Establishing health goals that include a multisector approach 3. Determining where interventions will have the greatest impact 4. Aligning with community partners to carry out the interventions 5. Measuring effectiveness of interventions by process, outcome, and impact evaluations -The BUMP needs to be further tested by communiiy/public health nursing research 1. However, by using an upstream approach, C/PHNs can impact the prevalence of disease within a population by intervening where the root causes exist

Answer 56

-This federal agency was established in December 1970 for the purpose of standard setting, monitoring, and enforcement of environmental protection in order to work for a cleaner and healthier environment for America -EPA is tasked with setting regulations based on scientific evidence that addresses environmental risks in homes, schools, workplaces, and natural environments

Answer 57

-It is important for nurses working in the community to identify priority environmental concerns where people spend the majority of their time (home, work, school) -Although community assessment and epidemiology are essential skills for public health nursing, the ability to perform critical assessments for environmental health requires background in the environmental health sciences

Answer 58

-In community/public health nursing practice, nurses routinely complete assessments for individuals, families, groups, and communities -There are many assessment tools available to help guide both C/PHN and the people they serve to assess environmental health risks

Answer 59

-The ecological model of public health offers a framework to consider where to target public health nursing interventions 1. The framework offers spheres of influence at individual, social sphere or family, community, and national levels 2. The nurse must first identify the needs of the targeted sphere by assessing the environmental risk -At the individual level, individuals should complete a personal environmental health exposure assessment 1. Ideally, this should be part of every health visit, workplace assessment, or other health history 2. Though there are some shared characteristics for environmental exposures, individual risks from work, home, school, and recreation all contribute to an individual's overall risk -The Agency for Toxic Substances and Disease Registry provides continuing education trainings to learn about a variety of environmental risks and how to take an exposure history -In addition, they created an environmental exposure history card using the mnemonic “I PREPARE” to aid nurses and other health professionals in adding environmental health exposure questions to patient assessment 1. This tool that is both brief and easy to remember can be incorporated into any health assessment easily -While completing an individual assessment, it is important to consider those exposures specific to the workplace, school, or neighborhood -Workplace exposures are often addressed by OHNs and include not only physical hazards such as injuries from machinery, burns, falls, and crushing injuries but also hazardous exposure to toxic chemicals, particulate matter in the form of dust, volatile organic compounds (VOCs) and aerosols, heavy metals, and other chemicals that can contribute to poor indoor air quality -School nurses often address students' exposures in school settings, but it is very important for C/PHNs to identify potential risks to educate parents about environmental hazards in schools 1. Similar to the workplace, many schools have issues of poor indoor air quality with the increased use of synthetics in building materials and reduced access to outdoor air 2. It is especially important to assess for hazards among school-aged children and the routes taken to school and playgrounds

Answer 60

-C/PHNs frequently conduct home assessments for case finding, follow-up, screening, or other public health services -Home assessments often involve looking for safety hazards in the home, but do not always include potential environmental exposures -During the home visit, C/PHNs must assess the home for environmental tobacco smoke; the possibility of asbestos, the presence of a carbon monoxide detector and heating sources; lead paint risk; the water source and the possibility of lead pipes; and other potential or actual hazardous materials -Depending on the region of the country, C/PHNs should ensure that the family has their home tested for radon -Likewise, family members should be reminded to safely dispose of unused medication and old mercury thermometers 1. Cleaning products, paints, varnishes, strippers and other home remodeling materials, gardening fertilizers and pesticides (which can be carried into the home on shoes or pets), pest management insecticides and other materials, air fresheners, and mold and moisture can all be sources of exposure in the home and land around the home -C/PHN must be well versed in identifying hazardous materials and assess for them in their routine home visits -Identify everyday products in clients' homes that contain hazardous materials and communicate to them the risk they pose to health and the importance of eliminating them or securing them to minimize risk of exposure -Finally, a home assessment should address nearby environmental hazards or potential hazards such as coal-fired power plants, farms, industries, brownfields (properties where pollutants, contaminants, or hazardous substances may be present), toxic waste sites, highways, and contaminated waterways 1. Frequently, these hazards are visible in the neighborhood, but often, there are hidden routes of exposure from contaminated groundwater, ambient air, and contaminated soil 2. It is important that the C/PHNs is aware of local industry and potential contaminations that can place families at risk in their home

Answer 61

-A comprehensive community health assessment considers environmental factors in a number of ways -Environmental assessment refers to the natural and built environments -Community assessment is central to public health nursing practice and to the core functions of public health 1. Typically, a windshield or walking survey is useful for observation of environmental hazards 2. By knowing likely hazards in the community, C/PHNs can identify many possible environmental risks simply by observation -Various tools have been developed to help nurses assess for environmental risks 1. Though most community assessment tools address environment, C/PHNs must also consider specific threats that may not be covered by general community assessments -To assess air quality, for instance, nurses should look for visible sources of air pollution from smokestacks, identify exhaust from vehicular traffic, and learn of significant industries, power sources, and incinerators in the community -To assess water quality, C/PHNs must identify the source of drinking water as public or private, understand water treatment and quality, recognize evidence of pollution and whether there are fish alerts for local waterways, examine stagnant water and possible waterborne risks, and identify issues related to sewer function and possible contamination, as well as the likelihood of floods and other water emergencies -To assess land, nurses must consider both current and former land use 1. Superfund refers to funding made possible by the Comprehensive Environmental Response, Compensation, and Liability Act of 1980 to address those contaminated areas of the United States that needed to be remediated; the EPA administers the funding 2. Well-known examples of Superfund sites in which land contamination caused public health disasters are Love Canal in New York State and Times Beach, Missouri 3. Nurses must be aware of such sites in their communities, which are listed on the National Priorities List and can be located by searching on the EPA Web site -Brownfield sites refer to real “property, the expansion, redevelopment, or reuse of which may be complicated by the presence or potential presence of a hazardous substance, pollutant, or contaminant” -In 2018, the Brownfields Utilization, Investment, and Local Development (BUILD) Act was ratified to bring more opportunities for sustainable local development and to redevelop brownfield sites that still required remediation 1. Nurses should monitor the impact of the BUILD Act of 2018 and advocate that the goals of this act serve their communities

Answer 62

-Community/public health nurses participate in the other core functions of public health for environmental health nursing -Policy development is the core function that addresses the need for legislation to protect human health 1. In addition, policy development also provides opportunities for nurses to engage with communities in addressing policies specific to their needs -To advocate for change, C/PHN must be informed about the community hazards, existing legislation, and governmental and nongovernmental groups that can be partners in the efforts to protect health -Nurses can begin their environmental advocacy by writing letters to their legislators in support of health-protective laws such as sustainable energy choices, improved air quality, or ecological agricultural practices -Important nursing actions related to environmental policy are to advocate for health-protective policies and to inform community members about the health risks related to the specific issue -Additionally, letters to local newspapers and periodicals can remind community members of safe practices in the home and personal environment -Nurses can also present testimony at public forums or hearings -As knowledgeable and trusted members of the community, C/PHN help to educate and empower community members; nurses in many other settings are also realizing the benefits of population-based advocacy -C/PHN serve on local and national committees and boards to advocate for change 1. Examples of agencies where nurses play an advocacy role are the Children's Environmental Health Network, Just Green Partnership, local and country environmental groups, state nurses association environmental affairs committees, and Health Care Without Harm, to name just a few 2. Nurses engaged in environmental health research can share the findings of successful environmental health nursing interventions to promote policy change -For nurses to function effectively as advocates for safer environments, it is essential to be aware of important legislation for environmental health 1. Nurses can also use the EnviRN Web site to follow current advocacy efforts in nursing practice

Answer 63

-The regulatory function for policy ensures that appropriate services are provided -This public health function demands that C/PHNs must incorporate environmental health principles into practice 1. For example, a nurse can educate families to reduce their risks from environmental hazards in the home, an OHN will ensure that safety regulations are followed in the work settings, or a school nurse can ensure that indoor air quality is monitored for the school setting -Assurance guarantees that policy and regulatory functions are followed through the provision of public health essential services

Answer 64

-To assure that nurses are prepared to address environmental risks to health in home settings, competencies for nursing education include home assessment strategies -Nurses working with families and in communities participate in research programs and collaborative projects that impact home environments -To address some of those health issues, particularly for children, the U.S. Department of Housing and Urban Development created the Healthy Home Intuitive (HHI) to protect children and their families from health and safety hazards in their homes 1. The program targets multiple childhood diseases and injuries in the home by using a comprehensive approach. Some of the environmental health concerns addressed include lead, carbon monoxide, pesticides, radon, mold, home safety, and asthma -In New York, the Erie County Health Department took an upstream approach and addressed lead exposure, carbon monoxide, falls, and burn risks for low-income families before they moved into their homes -In Ohio, C/PHN collaborated with other professionals (program manager, health educator, sanitarians, community outreach worker) through a Healthy Homes Program Grant to perform housing control assessments, education, and interventions in housing units 1. The interventions included home visits and education, and they were found to reduce asthma symptoms, school days missed, workdays missed, and the number of emergency room visits for asthma events 2. Results continued 6 months postintervention

Answer 65

-A second area for nurses to assure that essential services are provided to community members is in response to severe weather events -Although studies indicate that nurses are involved in disaster response, results indicate that nurses are not always prepared for their role in emergency response situations -The United States is experiencing more frequent and severe weather events -Loss of power and homes, and disruption of services from flooding, fires, earthquakes, tornados, and hurricanes, put many people at risk from natural disasters -Specific issues related to environmental risks that occur after severe weather events or disasters that are important for C/PHNs 1. These include power outages, safe water and food supply, wastewater, mold, toxic exposures, and poor air quality -For example, when there is a power outage, many families depend upon generators to supply electricity 1. These can be a source of carbon monoxide poisoning if not effectively functioning or not well ventilated 2. During cold weather, families may use wood or kerosene for heat that can pose danger of fire, explosion, and asphyxiation from carbon monoxide, but kerosene heaters can also emit other pollutants including carbon dioxide, nitrogen dioxide, and sulfur dioxide -In particular, pregnant women, asthmatics, individuals with cardiovascular disease, older adults, and young children are at particular risk from these toxic emissions 1. Nurses must inform community members of safety in the home when using alternate sources of heat or power -If a home is without power, there is a risk for food storage and safety 1. If the home has a well and water pump, there may not be access to potable water during the power outage 2. Community members should be informed of issues related to safe storage of food and the need to dispose of improperly refrigerated foods -Homes that have septic systems may find that they have overflowed if there is any flooding from a severe storm 1. It is important to understand when it is safe to return to well or septic system use after ground-level flooding -Floods also pose a problem to residents who have water enter their homes 1. Standing water can cause mold and mildew, possibly harm home furnaces, pose a risk of fire, and release toxins into the water and air -Small children and older adults are at more risk of environmental exposures during and after a natural disaster, and the C/PHN must address not only emergency planning but also safe remediation strategies to avoid toxic exposures among community members

Answer 66

-Provide information on the hazards of working with a chemical and procedures that should be used to ensure safety -A primary source of information regarding source of information regarding chemical hazards and handling

Answer 67

-In public health, the ecological model of population health is used to illustrate that determinants of health (biological, behavioral, and environmental) interact to affect health -In addition, the framework of planetary health relies on an ecological perspective to attain health, well-being, and equity through stewardship of the political, economic, and social systems as well as natural ecosystems -Using the ecological perspective of planetary health, nurses are able to collaborate to address social, political, economic, cultural, and natural environmental factors that influence human health within their practice setting -Nurses must engage in strategies to protect human health in their communities through the core functions of public health: assessment, policy development, and assurance -To effectively do this, nurses must think globally in order to be effective locally 1. This means adopting an ecological perspective related to impacts on human health -By broadening our perspectives, consideration of foods imported from countries around the world, toys made in other countries and used in the United States, and the manufacture of products in locations where the regulations for safety are not as stringent (or in some cases more stringent) as in the United States is helpful for nurses in addressing environmental health knowledge and advocacy -Nurses who endorse “green nursing” by promoting more ecological and environmentally safe practices in their workplace are making an impact upon global environmental health 1. The UN SDGs call on us to think more broadly as global citizens of the multiple factors that influence thriving communities and thus enhance human health -In order to fully promote the health of populations, nurses must take personal action to reduce their use of products (particularly those with toxic chemicals), reuse as much as possible, and recycle (in safe processes) to decrease their personal environmental footprint -Nurses must also incorporate the environmental health knowledge and skills mandated by the ANA Scope and Standards of Nursing Practice into their nursing practice

Answer 68

-Experts argue that the genetic changes that result from epigenetic processes because of developmental exposure to environmental stressors create negative effects on the health of future generations and contribute to rising rates of neurological conditions, alterations in reproductive organ development, and cancer -In addition, the effect of climate change on weather extremes (droughts, foods, and storms), changes in rainfall and water supply for soil, rising atmospheric greenhouse gases, and the ecology of microbial growth will have negative impacts upon the food supply

Answer 69

-Environmental Principles for Public Health Nursing -ANA’s Principles of Environmental Health for Nursing Practice -ANA’s Nursing: Scope and Standards of Practice, Standard 16 Environmental Health -Healthy People 2030 Initiatives -Core Functions of Public Health

Answer 70

-Dynamic communities that no organism including humans can exist outside of -Study of which provides an understanding of: 1. Relationship between humans and environment 2. Importance of knowledge of environmental health for nurses

Answer 71

-Based on need for humans and environment to coexist -Consideration of present and future needs 1. Food and fuel limitations of natural environment 2. Protection of environment 3. Promotion of healthy characteristics in population

Answer 72

-Precautionary principle 1 .“When an activity raises threats of harm to human health or the environment, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically” 2. Science and Environmental Health Network -Health risk assessment 1. Systematic evaluation of risk of specific exposure 2. Four steps *Identification of the hazard *Exposure assessment *Characterization of the health risk *Risk management -Health impact assessment 1. Systematic evaluation of a planned change to a community before change occurs 2. Six steps *Screening *Scoping *Assessment *Recommendations *Reporting *Monitoring and evaluation

Answer 73

-Environmental epidemiology -Toxicology -Risk assessment -Risk management

Answer 74

-Learn about possible environmental health threats -Assess clients’ environment and detect health hazards -Plan collaboratively with citizens and other professionals to devise protective and preventive strategies -Assist with the implementation of program -Take action to correct situations in which health hazards exist -Educate consumers and assist them to practice preventive measures -Take action to promote the development of policies and legislation that enhance consumer protection and promote a healthier environment -Assist with and promote program evaluation to determine the effectiveness of environmental health efforts -Apply environmentally related research findings and participate in nursing research

Chapter 6 And 9 Study Guide Flashcards

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