Abstract
Los Angeles County (LAC) restructured and reinvigorated public health in response to nationwide concern over the adequacy of all public health infrastructures and functions. LAC's reorganization into geographically defined service planning areas (SPAs) has facilitated the integration of core public health functions into local practice. Public health nurses practicing as generalists within their SPA identified three initial objectives to address in population-based care: (1) expanding practice beyond disease control to a more holistic approach, (2) providing consultation using the Ask-the-Nurse innovation, and (3) developing a community assessment database for interdisciplinary SPA health planning. Additional innovative objectives are planned for the future.
PUBLIC HEALTH in Los Angeles County (LAC) has undergone a major restructuring in the past four years. While still embracing its responsibility to provide primary/personal health care services for the medically indi-gent, the Department of Health Services (DHS) has recommitted itself to its primary public health mission of safeguarding and improving the health of all the 10 million plus residents of the county. A wide range of factors in the social, economic, and political environment, as well as biological considerations, has brought about recognition of the broader focus of the determinants of health, as depicted in the model by Evans and Stoddart.1 This model illustrates that it is too limiting to address health care from only a disease perspective, particularly when economic resources are limited. They recommend a framework that, in addition to disease and health functions, includes the social environment, physical environ-ment, genetic endowment, perception of well-being, and the individual's response behaviorally as well as biologically. In addition, Healthy People 2010 2 includes a similar framework for determinants of health in the formation of health goals for the United States during the 21st century.
LAC is unique in terms of its size and diversity. The county's population exceeds that of 42 states and comprises a geographic area as large as Rhode Island and Connecticut combined. It is the nation's second largest port of entry for immigrants, yet no single ethnic group constitutes a majority. It has the largest population living in poverty of any metropolitan area.3-5
LAC DHS provides its socially and ethnically diverse residents with a health care safety net, operating the nation's second largest publicly funded health care system. Each year nearly 1 million residents use its acute care/ambulatory care network of 6 hospitals, 6 comprehensive health centers, and 39 smaller satellite health centers scattered throughout the county. DHS also recently established partnerships with about 60 private providers, most of which are nonprofit, to further expand the number of primary care access points available to LAC residents.
Concerned about the state of its public health capacity, LAC commissioned a study6 in July 1997 by the University of California at Los Angeles (UCLA) School of Public Health. The study revealed the department's inadequacies in addressing core public health functions. It also identified a lack of coordination of services and a need for a clear mission statement or strategic plan. In addition, the study concluded the array of services and programs offered were primarily determined by funding agencies rather than the assessed needs of the county population.
In December 1997, new DHS leadership adopted an innovative mission and vision for public health. This new strategy, termed "Reinvigoration of Public Health," specified performance of basic public health functions such as health surveillance, disease prevention, and health-related, community-based activities. Its stated emphasis was improvement and maintenance of health for all residents of LAC. Funding was obtained for new programs in previously neglected areas such as chronic disease prevention and health assessment.
Reinvigoration also called for the decentralization of operational management into eight geographically defined service planning areas (SPAs; see Figure 1). SPA health offices were established and headed by area health officers (AHOs). The goal of each AHO is to facilitate closer coordination of local planning, strengthening of public-private partnerships, and improving the health of communities within the SPA. Public health nursing, as a highly visible practice in the community, plays a vital role in the public health reinvigoration plan. Nursing joined other professionals, such as health educators and epidemiologists, to form SPA-based public health teams.
Paralleling LAC restructuring efforts, there was a nationwide recognition that health promotion and preventive services were key components of health care reform.7 The Public Health Nursing Section of the American Public Health Association (APHA) updated its definition of public health nursing as "the practice of promoting and protecting the health of populations using knowledge from nursing, social and public health sciences."8 (p. 1) Some models of population-focused public health nursing practice emerged. Among the most noteworthy was the interventions model, which defines and describes 17 public health nursing interventions and provides examples of the individual, community, and systems levels of practice.9 Another significant influence on the goals and directions of public health nursing was the American Nurses Association publication titled Scope and Standards of Public Health Nursing Practice,10 which defines the practice of public health nursing.
LAC public health nursing was provided the opportunity to revitalize its scope and standards of practice, emphasizing its unique linkages and activities in the community. This opportunity was fueled by the support and clearer delineation of its role through researched and developed models and guidelines. The LAC Public Health (PH) department employs about 500 public health nurses (PHNs). Of these, 200 PHNs are generalists whose area of practice is based on assigned census tracts and the residents within them. Their base of operation is the PH district health center, hence the term district public health nurse (DPHN) that is synonymous with the generalist practice PHN. In the past, the primary focus was communicable disease control and assessment of sporadic referrals related to health concerns such as lead levels, Sudden Infant Death Syndrome (SIDS), and so on. To varying degrees, the DPHN had participated in various committees, outreaches, coalitions, and other community-based activities. However, these community activities had not been linked to local area planning, establishment of goals and objectives, or outcome measures.
The remaining 300 PHNs are assigned to one of nine different programs (e.g., foster care, maternal child health, sexually transmitted diseases, tuberculosis). The practice focus for these program PHNs is directed by a targeted population such as mothers or children or those with a particular disease such as tuberculosis.
The multidimensional activities, multiple work settings, and hundreds of professional nurses require several practice-specific objectives to meet DHS's systemwide goals for reinvigoration. The initial objectives addressed in this reinvigoration process were directed to (1) expand beyond the categorical focus of mandated communicable disease control, (2) provide DPHN consultation in the community setting, and (3) participate as an SPA multidisciplinary team member in planning and intervention. At this point in time this process is directed at only the DPHNs; there are plans to include those PHNs in the programs within the next two years.