Community and public health nurses use a set of tools to reach individuals, families, and populations:

The Public Health Intervention Wheel (Minnesota Department of Health) organizes 17 interventions at three levels of practice: individual/family, community, and systems. The interventions are grouped in wedges:

• Surveillance, disease and other health event investigation, outreach, screening, case-finding
• Referral and follow-up, case management, delegated functions
• Health teaching, counseling, consultation
• Collaboration, coalition building, community organizing
• Advocacy, social marketing, policy development and enforcement

A single problem (for example, childhood lead poisoning) is best addressed at all three levels: case management of a poisoned child, community education and screening, and systems change such as housing code enforcement.

Community assessment methods

• Windshield survey — driving or walking through a neighborhood to observe housing, businesses, services, transportation, people, signs of decay or vitality; quick, inexpensive, but superficial
• Key informant interviews — formal leaders (officials, clergy, principals) and informal leaders (long-time residents)
• Participant observation — taking part in community life to observe norms and interactions
• Focus groups and community forums — small in-depth discussions versus large open meetings
• Surveys — standardized data from a sample
• Secondary data — census, vital statistics, disease registries, BRFSS and YRBSS surveys, county health rankings, hospital data

Community-as-Partner model (Anderson and McFarlane): the community core (history, demographics, values, beliefs) is surrounded by eight subsystems — physical environment; health and social services; economy; transportation and safety; politics and government; communication; education; and recreation.

Community health needs assessments (CHNAs). Under the Affordable Care Act, tax-exempt hospitals must conduct a CHNA and adopt an implementation strategy every 3 years. Local health departments conduct community health assessments and improvement plans, often using frameworks such as MAPP (Mobilizing for Action through Planning and Partnerships).

Home visit phases

1. Initiation — clarify the referral source, purpose, and client's consent
2. Previsit preparation — review records and discharge summary (diagnoses, medications, orders, follow-up plan), call to schedule, plan the route, check safety, gather supplies
3. In-home phase — introduction and relationship building, assessment (client, family, home safety, environment), interventions and teaching, mutual goal setting
4. Termination — summarize, confirm understanding, plan the next visit or discharge
5. Postvisit — documentation, communication with the team, referrals and follow-up

Advantages and limits of home visits

• Advantages: see the real environment and family dynamics, tailor teaching to available resources, clients are more comfortable, reaches those who cannot travel
• Limits: costly in time and travel, distractions, possible safety risks

Case management process (Case Management Society of America Standards of Practice, revised 2022): client identification and screening → comprehensive assessment → identification of problems and opportunities → planning with the client → implementation and care coordination (including transitions of care) → monitoring and evaluation of outcomes → closure. Case management is collaborative and client-centered; its goal is the client's optimal function and quality of life with cost-effective, safe care — not simply fewer hospital days.

Home visit safety

• Know the neighborhood; visit in daylight when possible; give the agency your itinerary and check in
• Keep the car fueled and locked, park where you can leave easily, carry a charged phone
• Trust your judgment: if there is a threat (weapons displayed, intoxicated or violent person, illegal activity), leave and reschedule; call 911 in an emergency; report to the supervisor
• A visit can be done with an escort or moved to a neutral site when risk continues

Bag technique (infection control)

• Place the bag on a clean, dry, hard surface on a barrier (paper towel or clean pad), away from children and pets
• Perform hand hygiene before taking items out of the bag and after care
• Take out only what is needed; clean reusable equipment before returning it to the bag
• Dispose of sharps in a puncture-resistant container; never leave sharps or medications within reach

Medicare home health (common exam content)

• The client must be homebound (needs help or a device to leave home, or leaving is medically inadvisable, and leaving home normally takes considerable and taxing effort; brief absences for medical care, religious services, or adult day care are allowed)
• Needs intermittent skilled nursing or therapy
• Under the care of a physician or allowed practitioner who certifies eligibility and approves the plan of care
• A face-to-face encounter related to the main reason for care within 90 days before or 30 days after the start of care
• Agencies complete the standardized OASIS comprehensive assessment, which also drives quality measures and payment
• Medicaid, private insurance, and grants fund other home care; public health home visiting (such as Nurse-Family Partnership) is prevention-focused and has its own eligibility

Case management in practice

• Assessment is comprehensive: health status, function, medications, cognition, mental health, finances, housing, caregiver capacity, cultural preferences
• The plan is built with the client; goals reflect the client's values
• Connect formal resources (home health, adult day services, meal delivery, transportation, benefits) and informal resources (family, neighbors, faith community)
• At every transition: medication reconciliation, a clear follow-up appointment, and a named contact person
• Evaluate outcomes broadly: health status, function, quality of life, client satisfaction, appropriate use of services, and cost

• Care coordinator — links services and prevents gaps or duplication
• Advocate — speaks up for the client's rights and needs (for example, pushing for home safety repairs through local volunteer programs)
• Educator and counselor — self-management teaching using teach-back and return demonstration
• Case finder — identifies people at risk who are not yet receiving care
• Collaborator — works with social workers, therapists, physicians, community agencies
• Supervisor — directs and supervises home health aides and other unlicensed personnel according to the state Nurse Practice Act; the RN retains accountability for assessment, planning, teaching, and evaluation, which are not delegated
• Scope limits — nurses do not diagnose medical conditions or prescribe (for example, starting oxygen needs a prescriber's order); RNs manage and teach prescribed therapies and report changes

• Autonomy and informed choice: clients may refuse services; the case manager gives options and information but does not make the decision for a competent client
• Privacy: HIPAA applies to health care providers and agencies; protect records in the car and at home visits, avoid discussing care in front of visitors without the client's permission
• Mandated reporting: suspected child abuse or neglect must be reported to child protective services; suspected abuse, neglect, or exploitation of older or dependent adults is reported to Adult Protective Services under state law; the child's or adult's safety comes first
• Documentation: accurate, objective, timely records of findings, care given, client responses, and communication; home health records must support eligibility (such as homebound status) — never overstate it
• Abandonment: terminate services through proper discharge planning and handoff, not by simply stopping visits
• Cultural humility and language access: use qualified interpreters; respect family decision patterns while protecting the client's rights

Case 1 — Unsafe visit. On arrival, the nurse hears shouting and sees a man waving a knife in the doorway.

Action: do not enter; leave the area, call 911 if anyone is in danger, notify the supervisor, and reschedule with an escort or at another site.

Why: nurse safety comes first; care cannot be delivered in an unsafe setting.

Case 2 — Poststroke client. A client after stroke lives alone, cannot manage stairs, and needs therapy and help with meals.

Action: after a comprehensive assessment, plan with the client and coordinate home health therapy, meal delivery, a personal emergency response system, and adult day services; monitor and adjust.

Why: coordination of formal and informal resources is the core case management function.

Case 3 — Palliative care decision. A client with advanced cancer is unsure about hospice. The daughter asks the nurse to "just sign him up."

Action: explain hospice and other options to the client, explore his goals, and support his own decision; involve the daughter only as the client wishes.

Why: case managers respect self-determination; deciding on behalf of a competent client violates autonomy.

• Starting case management with planning — the first step is identification and assessment
• Measuring case management success only by reduced admissions; the ultimate goal is independent function and quality of life
• Thinking a windshield survey includes interviews — it is observation; interviews with leaders are key informant interviews
• Taking items out of the nursing bag before hand hygiene, or placing the bag on the floor or bed
• Continuing a visit despite a clear threat
• Assuming "homebound" means bedbound — clients may leave for medical care and short, infrequent nonmedical absences
• Delegating assessment or teaching to a home health aide
• Treating referral as complete when the form is sent; follow-up confirms the client received the service

• Public Health Intervention Wheel: 17 interventions, three levels (individual/family, community, systems)
• Community assessment: windshield survey (observation), key informants, participant observation, focus groups, forums, surveys, secondary data
• Community-as-Partner: community core plus eight subsystems
• Home visit phases: initiation, previsit, in-home, termination, postvisit; review discharge summary before the first visit
• Safety: leave if threatened; agency knows your itinerary
• Bag technique: clean barrier, hand hygiene before removing items, clean equipment before returning it
• Medicare home health: homebound, intermittent skilled need, certified plan of care, face-to-face encounter 90 days before or 30 days after start, OASIS
• Case management: assess → plan with the client → coordinate → monitor → evaluate → close; client-centered and outcome-focused
• RN does not delegate assessment, teaching, or evaluation; nurses do not prescribe
• Report suspected child abuse to child protective services and suspected elder abuse to Adult Protective Services