In the 1990s, the state of New York pioneered quality assessment and improvement in the management of HIV/AIDS in community health clinics, drug treatment centers, and hospitals (New York State Department of Health AIDS Institute, 2003). The program proved so successful that it soon became the model for a national effort at assessing and improving treatment and care for people with HIV (IOM, 2004b). Similarly, studies have found that improving nurse-to-student ratios in public schools results in higher immunization rates, increased vision screenings and more effective follow-up, and significant gains in identifying asthma and life-threatening conditions. As more care moves from the acute to the community setting, quality measurement must expand to ensure that quality care is maintained throughout the transition.
Investments in community care can improve access and value as well. In the 1990s, the Department of Veterans Affairs (VA) began shifting its programs from the acute care to the community setting, dramatically increasing the number of veterans who were able to access care (CBO, 2009; VA, 2003) while improving health outcomes and lowering costs per patient (Asch et al., 2004; CBO, 2009; Jha et al., 2003; Kerr et al., 2004). Likewise, community health centers and nurse-managed health centers have provided quality, high-value care in many socially disadvantaged neighborhoods.
Providing care for underserved populations in community settings has long been a major goal of the nursing profession. Box 2-4 illustrates how one public health nurse provides infant care, primary care, environmental health services, and care to individuals with infectious diseases in the community. In another example, Lilian Wald founded the Visiting Nurse Service of New York (VNSNY) in 1893 to help improve the health and social outcomes of those with lesser means. Today, VNSNY is the largest nonprofit home health care agency in the United States (IOM, 2010).
A growing number of nurses are embracing technology to expand care in the community. A study conducted in Florida showed that telehealth services brought directly to patients’ communities and provided by nurses may increase access to care for children with special health care needs in rural, medically underserved parts of the state at no additional cost (Hooshmand, 2010). The alternative for these patients was to travel many miles, usually to an academic health center, to the site of a doctor’s office.