PUBLIC HEALTH NURSING

+--------------+-------------+-------------+-------------+-------------+
|              | 2002        | 2003        | 2004        | Increase    |
|              |             |             |             |             |
|              | Actual      | President's | Estimate    | or Decrease |
|              |             |             |             |             |
|              |             | Budget      |             |             |
+--------------+-------------+-------------+-------------+-------------+
| BA           | \           | \           | \           | +           |
|              | $37,781,000 | $39,875,000 | $43,112,000 | \$3,237,000 |
+--------------+-------------+-------------+-------------+-------------+
| FTE          | 278         | 288         | 305         | +17         |
+--------------+-------------+-------------+-------------+-------------+
|              |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| \# of        | 383,456     | 383,456     | 383,456     | 0           |
| Patient      |             |             |             |             |
| Visits       |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| \# of Home   | 153,000     | 153,000     | 153,000     | 0           |
| Visits       |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+

**[PURPOSE AND METHOD OF OPERATION]{.underline}**

Because of the increasing user population, the Indian Health Service
(IHS) Public Health Nursing (PHN) faces unique challenges in providing
services to a diverse population whose health care needs range from
simple to complex nursing care in the home or other community settings.
The Public Health Nurse is a major link to access to health care for
some American Indians and Alaska Natives who live in rural and isolated
communities.

The threat of bioterrorism has brought additional responsibilities for
the public health nurse through disease/health surveillance for a
hospital, health center and community, with some collaboration with
county/state health departments.

[Program Mission/Responsibilities]{.underline}

The IHS Public Health Nursing integrates nursing practice and public
health practices to individual families and groups thereby impacting the
health of the community. The tribes operate approximately one third of
the PHN programs through self determination compacts or contracts. The
public health nurses outreach activities include: home visits, well
child examination in remote communities, immunizations, prenatal care,
patient education/counseling and follow up visits for skilled nursing
services for those clients who require those services.

The majority of American Indians and Alaska Natives who live on
reservations live in rural and isolated community where access to modern
convenience such as telephone and transportation may not be available to
access medical care. Access to medical care is also a challenge for some
American Indian and Alaska Native members who live in urban areas and
often the PHN is the link to health care in those remote or isolated
urban and rural communities.

The public health nursing continues to be one of the most visible and
well known programs to the American Indian tribes because it is
community based. Their services are based on assessed needs of
individuals, families, groups, and communities. The PHN role is one of
health education, strengthening relationships with the Indian community
and providing the framework for broadly based community efforts, which
include: nutrition therapy, counseling, education, coordination of care
by referring clients to other health disciplines and case management
activities. The public health nurse collaborates with members of the
health care team to deliver the required services.

[Best Practices / Industry Benchmark]{.underline}

The Public Health Nursing program is integrated into the
IHS/Tribal/Urban (I/T/U) health programs. Home visits continue to be a
mainstay of the PHN activities along with case finding which together
accounts for over 40 percent of the public health nurses time. Another
50 percent of the public health nursing time is spent in activities for
children and adolescent under the age of 18 which is a collaborative
effort with the Maternal and Child Health (MCH) team.

Because the PHNs are community based their coordination of care includes
health counseling and client education for a variety of health
conditions. Community assessment and developing population based plan of
care is also another activity that PHN are involved in. Collaboration
with State and county agencies to plan appropriate programs to meet the
needs of the American Indian/Alaska Native community often requires
input from the I/T/U PHNs.

[Finding Influencing FY 2004 Request]{.underline}

Public Health Nursing services related to preventive care are directly
influenced by PHN home visits, including prenatal care, high
immunization rates, post hospitalization home visits for skilled and
unskilled nursing services which prevents or delays readmission into a
health care facility.

The IHS service population is increasing at a rate of about 2.1 percent
per year. The health needs of the growing elder population require
20 percent of the PHNs home visits. There is increasing emphasis to
address the American Indian and Alaska Native health disparities, for
example, certain American Indian and Alaska Native women have higher
rates of cervical cancer. PHNs make home visits to educate at risk women
and encourage early screening and follow up to missed appointments.
Additionally, the American Indian and Alaska Native population have a
higher incidence and prevalence of diabetes mellitus and its
complications. PHNs conduct home visits to educate the importance of
glycemic control to delay the onset of complications based on a plan of
care. Hypertension and heart disease are often co-existing conditions
with diabetes.

PHNs collaborate with other health care providers on the Maternal and
Child Health care team to improve health outcomes for the mother and
child. The American Indian and Alaska Native population is a young
population with greater than 50 percent in the childbearing years. PHNs
make home visits to increase first prenatal visits in the first
trimester and additionally home visits are made to those prenatal
patients who have risk factors such as smoking, alcohol and drug use in
pregnancy which correlate with poor outcome for the baby. There is
documentation that mothers and their children who receive PHN home
visits have better outcome (Olds et. al, 1998).

In FY 2001, 45 percent of the PHNs services were to maternal, child
health promotion.

There are pockets of infectious disease outbreak in various American
Indian/Alaska Native communities, such as Tuberculosis, Hantavirus and
Syphilis, which require stringent investigation of the environment and
education on prevention to the individual families involved and to the
public.

**[ACCOMPLISHMENTS]{.underline}**

In FY 2001, the public health nurses spent over 20 percent of their work
load in activities that involved work with the elderly patient in the
community. Some of these activities included environmental assessment
and health screening activities and updating flu immunizations.

The public health nursing also spent over 45 percent of their time in
maternal and child health activities. These include visits for
immunizations, prenatal and post partum care to those clients requiring
those services. Services were also provided to school and adolescent
population for prevention health screening and disease prevention
education.

Additional responsibilities assumed by the public health nurses are
health and disease surveillance for the health care facility and
community. Some of the activities require coordination and collaboration
with county and State health departments. This has become a pivotal
responsibility for some public health nursing programs since September
11, 2001 and the focus on bioterrorism.

#### **PERFORMANCE MEASURES**

The Public Health Nursing budget contributes to the accomplishment of
the following FY 2004 performance measures:

[Indicator 7]{.underline}: During FY 2004, maintain the proportion of
eligible women who have had a Pap screen within the previous three years
at the FY 2003 levels.

[Indicator 8:]{.underline} During FY 2004, maintain mammography
screening at the FY 2003 rate.

[Indicator 23:]{.underline} During FY 2004, maintain the total number of
public health nursing services (primary and secondary treatment and
preventive services) provided to neonates, infants, and elders in all
settings and the total number of home visits at the FY 2003 workload
levels.

[Indicator 24]{.underline}: During FY 2004:

a\. increase the rates for all recommended immunizations for American
Indian and Alaska Native children ages 3‑27 months by 2% over the FY
2003 rates

b\. establish baseline rates for recommended immunizations for American
Indian and Alaska Native children 19‑35 months.

[Indicator 25]{.underline}: In FY 2004, maintain the FY 2003 rate for
influenza vaccination levels among non-institutionalized adults age 55
years and older.

[Indicator 26]{.underline}: In FY 2004, maintain the FY 2003 rate for
pneumococcal vaccination levels among non-institutionalized adults age
65 years and older.

Following are the funding levels for the last 5 fiscal years:

+-----------------+-----------------------------+---------------------+
| # Year          | **[Funding]{.underline}**   | **                  |
|                 |                             | [FTE]{.underline}** |
+-----------------+-----------------------------+---------------------+
| 1999            | \$30,363,000                | 284                 |
+-----------------+-----------------------------+---------------------+
| 2000            | \$34,452,000                | 287                 |
+-----------------+-----------------------------+---------------------+
| 2001            | \$37,646,000                | 274                 |
+-----------------+-----------------------------+---------------------+
| 2002            | \$37,781,000                | 278                 |
+-----------------+-----------------------------+---------------------+
| 2003            | \$39,875,000                | 288                 |
+-----------------+-----------------------------+---------------------+

**[RATIONALE FOR BUDGET REQUEST]{.underline}**

[TOTAL REQUEST]{.underline} \-- The request of \$43,112,000 and 305 FTE
is an increase of \$3,237,000 and 17 FTE over the FY 2003 President's
Budget request of \$39,875,000 and 288 FTE.

# Pay Cost Increases: +\$603,000

The request of \$603,000 will fund federal and tribal pay costs which
will assist the IHS in maintaining access to services for the IHS
patient population. Provision of these funds is necessary to maintain
the current I/T/U health system which works to eliminate disparities in
health status between the American Indian and Alaska Native population
and the rest of the U.S.

#### Phasing-In of Staff for New Facilities: +\$2,634,000 and 17 FTE

The request of \$2,634,000 and 17 FTE provides for the phasing-in of
staff and related costs for new facilities allowing IHS to expand
services in areas where existing capacity is most extended. The staffing
of new facilities also contributes to the recruitment and retention of
medical staff and promotes self-determination activities. The following
table displays the requested increase.

+--------------------------------+---------------+---------+---------+
| **[Facilities]{.underline}:**  | ##            | ###     | ######  |
|                                | # **Dollars** | ### FTE |  Tribal |
+--------------------------------+---------------+---------+---------+
| Ft. Defiance, AZ Hospital      | \$843,000     | 9       | 0       |
|                                |               |         |         |
| Pawnee, OK Health Center       | 763,000       | 8       | 0       |
|                                |               |         |         |
| Winnebago, NE Hospital         | [1,028,000    | [       | [1      |
|                                | ]{.underline} | 0]{.und | 1]{.und |
| **Total**                      |               | erline} | erline} |
|                                | **            |         |         |
|                                | \$2,634,000** | **17**  | **11**  |
+--------------------------------+---------------+---------+---------+