Running Head: COMMUNITY HEALTH PROMOTION

Community Health Promotion in Neurological Medicine

Delaware Technical Community College

NUR 330 Population and Community Health

Andrea DiMartino, RN
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Community Health Promotion in Neurological Medicine

Neurological medicine is a field of nursing that offers many facets and specializations for

skilled nursing care to address client needs based on several neurological conditions. Working

with neurologists, neuroscience nurses help to build a plan of care for patients and help them

navigate new and sometimes overwhelming disease processes. In addition to regular assessments

and ongoing communication with the patients, neuroscience nurses help patients to understand

their new medications, advocate for them to get the best possible treatments, arrange for

specialized equipment and services, and ensure that they are getting the varied treatments that are

required based on their condition. With so many different disease processes under the umbrella

of neurological conditions, the neuroscience nurse has an ever evolving but satisfying role to

play in neurological medicine. For the scope of this project, the population of a local neurology

practice will be evaluated.

The Neurological Medicine Population

It would be difficult to give a concise cross section of demographics for the neurological

patient population. They range in age from young children with complex needs to octogenarians

who are in otherwise excellent health, but their neurologic systems are failing them. The best

way to classify patients seen in a neurological practice would be to separate them into the seven

categories set forth by the American Board of Neuroscience Nursing. Those categories are

trauma, cerebrovascular, tumor, seizure, immune and infection, chronic neurological, and

pediatric and developmental (The American Board of Neuroscience Nursing, 2020). Within the

local outpatient practice Christiana Care Neurology Specialists, a majority of patients fall under

cerebrovascular, seizure, and immune or infection with only a few being seen for traumas, and

most tumor patients being managed by oncology practices. There are some specialized
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practitioners who focus on some of the chronic neurological disorders, and one practitioner who

specializes in the pediatric neurological population.

The first category, cerebrovascular, comprises approximately 20 percent of the

population of the practice. Cerebrovascular issues that are addressed in neurology include stroke,

both hemorrhagic and ischemic, transient ischemic attacks, and anoxic injuries. Most of the

needs for this population are addressed in the acute stage in an inpatient setting, then follow-up is

completed through the office. Much of the follow-up care for this population involves physical

therapy, medication changes, and counseling. The overall care from a neurology office for this

population is temporary, often being passed on to the primary care to manage medications that

require ongoing prescription monitoring and testing. The role for nurses in this category is vital

as they meet with these patients to help them to understand the ways in which they can alter their

modifiable risk factors to reduce the risks of future injury, such as smoking cessation, diet, and

exercise, and ensure patients understand their new medications and plan of care.

Next, the seizure population is another portion of the practice, encompassing about 10

percent of the total patient population. The patients seen for seizure disorders include those with

Epilepsy and other causes such as lasting trauma from injury. The ongoing needs of this

population include medication management, care coordination, and patient safety. Often, seizure

disorders leave patients unable to work, or need to find work with accommodations that must be

backed by the Americans with Disabilities Act. In America, approximately one percent of the

population suffers from epilepsy (So, 2014). For all of these issues, plan of care is coordinated

by a nurse that monitors medication refills and insurance authorizations, schedules and oversees

epilepsy studies, and ensures that required forms and applications are completed so that there are

no gaps in care or employment if applicable. At times when there are medication shortages on
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anti-seizure medications, which happens frequently in the United States, the nursing staff will

work with the patient to locate pharmacies that have their dosages in stock or work with

physicians to identify and arrange alternative dosages and frequency temporarily to ensure

patient safety by preventing interruption in their seizure prevention plan.

The third category of patients is the infection and immune population. This includes

Demyelinating Polyneuropathy such as Guillain-Barre, Bell’s Palsy, and Myasthenia Gravis,

however, the majority of patients seen in the practice at Christiana Care Neurology Specialists

for this category, about 30 percent of the overall practice, have a diagnosis of Multiple Sclerosis.

For these patients, a primary focus of nursing intervention is proactive symptom management by

educating patients on ways to reduce recurrence including diet changes, regular exercise, and

stress reduction methods. Additionally, nurses help patients to navigate medication changes and

monitoring, testing scheduling, and insurance requirements including authorization for their

medication and imaging needs.

Finally, the category of chronic neurological disorders encompasses patients being seen

for dementia, movement disorders such as Parkinson’s Disease, chronic migraine, and sleep

disorders. In many practices through the country, neurology offices also oversee the management

of chronic neuropathic pain management and other pain management issues, however in

Delaware that is addressed in other practices that specialize specifically in pain management to

ensure improved oversight and patient safety. Nurses help to coordinate insurance issues for

testing and medications for diagnosis and symptom management, as well as working with

patients to identify community resources available to them including physical therapy, cognitive

therapy, and other multidisciplinary specialties (Christiana Care, n.d.).

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Challenges and Barriers for Neurologic Patients

When the Healthy People goals were updated from 2010 to 2020, several new categories

were introduced that specifically impact the neurological specialty. Aligning practice goals with

the newly established goals of Healthy People 2020, there are several categories and goals which

impact the neurological population including dementias and Alzheimer’s Disease, health-related

quality of life & well-being, nutrition and weight status, heart disease and stroke, older adults,

and sleep health (Office of Disease Prevention and Health Promotion, 2019). Many of these

goals overlap within the neurological patient populations and are addressed by nurses helping to

care for patients within these populations. Each patient’s situation is different, but many rely on

Medicare for their health insurance and often there are barriers with health insurance coverages

regardless of provider to ensure that prescribed medications are covered. Out-of-pocket costs for

patients can force them to make health decisions based on budgeting leaving them vulnerable to

exacerbations or reoccurrences when they cannot afford to take their medications as prescribed.

In regard to the dementia population, the Healthy People 2020 goal is to “Reduce the

morbidity and costs associated with, and maintain or enhance the quality of life for, persons with

dementia, including Alzheimer’s disease.” (Office of Disease Prevention and Health Promotion,

2019). With the addition of the Swank Center for Memory Care in Delaware, the population has

access to improved services including adult day cares to help keep patients in their home

environment longer to improve the mortality rate while providing supervision while caregivers

are at work. Additionally, there are multiple therapies available through the Swank Center that

help promote cognitive function and slow the decline of recollection and decision-making

through a multidisciplinary approach. Though the programs offered are promising, it can be

difficult for patients to qualify to join these programs, or even for a diagnosis to happen early
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enough for memory care programs to be beneficial. For caregivers that work unusual hours, there

are still struggles to find people to care for their family member who has dementia, which can

still force families to make the decision to suffer a loss of income or move the family member

into a long-term care facility. Additionally the portion of care covered by Medicare does not

necessarily make care affordable for many families and can increase risks of patient falls and

elopement if they are unsupervised at home because the family can’t afford alternative care

options. According to the Office of Disease Prevention and Health Promotion, approximately

25% of adults age 18 or older in the United States provide care or assistance to someone with a

disability or long-term illness (2019). As programs continue to become available, there is the

possibility of improvement in these situations for caregivers, but for now the options continue to

be limited.

The Office of Disease Prevention and Health Promotion also identified heart disease and

stroke prevention as another of the Healthy People 2020 goals (2019). Though the Christiana

Care Neurology Specialists do not tend to see patients until after the initial stroke event, the

focus is on prevention of further injury while educating patients on modifiable risk factors.

Those factors include high blood pressure, high cholesterol, cigarette smoking, diabetes,

unhealthy diet, physical inactivity, and obesity. With such a large portion of the American

population being classified as obese or overweight, one of the largest challenges is encouraging

weight loss and promoting exercise. Often, patients have a limited income due to retirement or

disability and find it difficult to budget for the healthful foods that promote wellness. At times,

patients are reliant on community resources to provide meal services and struggle to find a

balance between dietary needs and their ability to provide for themselves. Advanced age,

comorbidities, and disability also reduce the ability for patients to pursue increased physical
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activity. Along with advanced age often comes comorbidities and chronic conditions, and as our

population lives longer, there is a greater prevalence of these disease processes. Patients who

have suffered stroke or other issues often also are managing diabetes and other processes which

impair their overall health and can impair cardiovascular systems further increasing risk of

additional injury or complication (Office of Disease Prevention and Health Promotion, 2019).

Interventions and Evaluation for Goals

The goal of the nurses at Christiana Care Neurology Specialists should be to provide

family-centered patient care that is compassionate and effective for treatment of neurological

problems and the promotion of health. This goal should be addressed through nursing

intervention in a multi-faceted approach focused on health promotion. First, nursing should

identify patients and caregivers who are new to the practice and establish meetings with those

families to discuss concerns while establishing and reviewing the plan of care. At the time of

scheduling patient should be given an opportunity to schedule with nursing staff near to the time

of their physician appointment to promote nursing involvement and improve health promotion by

increasing opportunities for patient teaching. During patient meetings nursing should utilize the

opportunity to identify patients who are at risk for medication non-compliance and require

financial assistance with medications, such as Ocrevus for Multiple Sclerosis patients. The nurse

should then assist patients in locating resources and refer them to financial assistance programs

that the patient can apply for, such as hardship and copay assistance programs available through

the manufacturer (Genetech USA, Inc., 2020).

With the focus on health promotion, nursing roles should shift to a more proactive

patient interaction and education program to help patients understand healthier lifestyle choices.

The needs of the varied populations under the umbrella of neurosciences offer a multitude of
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opportunities for nursing to advocate for the health of their patients. Community programs

include meals in adult day programs including those at the Swank Center for Memory Care.

Patients who have limited mobility qualify for programs such as Meals-On-Wheels in Delaware

and the presence of a caregiver does not necessarily disqualify patients with limited income.

Services include scheduled delivery of nutritious hot meals based on a balanced diet (Meals on

Wheels Delaware, 2020). Additional dietary recommendations and education, as well as

suggestions for increased activity opportunities would be based on the patient needs and disease

processes. Again utilizing the example of Multiple Sclerosis, calorie-restriction based weight

loss plans and low-impact exercise programs are available through various sources including the

MS Society (2020). For members of the senior community who are more ambulatory but need to

increase their activity levels, there are multiple programs available throughout Delaware

including regular exercise programs that are low or no cost options through the Newark Senior

Center and YMCA of Delaware. Even in the current situation with closures due to Coronavirus,

there are online classes available for fitness and health promotion at no cost (YMCA of

Delaware, 2020).

Effective treatment of patients requires a thorough understanding of the disease

processes for which the patients in the practice are being treated. Nursing staff should be

evaluated on a regular basis for competency within the various disease processes to address any

short-comings. Nurses should be encouraged to complete and maintain their neurosciences

certification and seek-out continuing education programs which expand their understanding of

the patient populations treated within the practice. Since the certification requires either

additional education or re-testing every 3 years, staff would have an expanding and verified

knowledge base to address the specific needs of the patient populations discussed above.
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Evaluation of the interventions would be accomplished by reviewing the outcomes of a

small cohort of patients at regular intervals throughout year. Tracking data including medication

adherence and improvement of condition or reduction in recurrence of symptoms are strong

indicators of the effectiveness of nursing health promotion interventions. Additional assessment

data collected with each patient visit including vitals and weight give an indication of trends in

weight and blood pressure and can help nursing to identify if interventions have been successful

or require additional teaching. Teaching methods should include varied materials for patients to

review in addition to in-person education utilizing teach-back methods to ensure that teaching

has been successful. In addition to tracking outcomes for the patients based on data collected,

assessments of patient’s perceived health promotion should be evaluated through patient

satisfaction surveys. Patients who have been identified by nursing as candidates for teaching

should be provided a survey to determine adherence to plans, understanding of teaching, and

give patients an opportunity to express any questions or concerns they have about their care.

With such a diverse population with varied needs, the challenges to nursing to balance

comprehensive care with a strong knowledge base can be a steep hill to climb. Focus on

maintaining open dialogue with a commitment to enriching the patient experience through

empowerment and education is the strongest approach that neuroscience nursing can use to

accommodate for the needs of the population served at Christiana Care Neurology Specialists.

Continuing to proactively coordinate in a multidisciplinary team with varied specialties and

varying approaches based on the needs of each patient and family ensures they get the best

possible care with the most beneficial future outcomes.

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References

Christiana Care. (n.d.). Swank Center for Memory Care and Geriatric Consultation. Retrieved

from https://christianacare.org/services/seniors/swankmemorycare/

Genetech USA, Inc. (2020). OCREVUS Access Solutions. Retrieved from

https://www.genentech-access.com/patient/brands/ocrevus.html

Meals On Wheels Delaware. (2020). Together we can end senior hunger. Retrieved from

https://mealsonwheelsde.org/

National Multiple Sclerosis Society. (2020, April). Resources & Support. Retrieved from

https://www.nationalmssociety.org/Resources-Support

Newark Senior Center. (2020). Newark Senior Center Programs: Newark, DE - Official Website.

Retrieved from https://newarkde.gov/955/Newark-Senior-Center-Programs

Office of Disease Prevention and Health Promotion. (2019, November 21). 2020 topics and

objectives. Retrieved from Healthy People 2020 website: https://www.healthypeople.gov

/2020/topics-objectives

So, E. L. (2014, January 16). Profile of Epilepsy as a Disability. Retrieved from

https://www.aesnet.org/clinical_resources/practice_tools/employment_resources

/profile_of_epilepsy_as_a_disability

The American Board of Neuroscience Nursing. (2020). Certified Neuroscience Registered Nurse

(Cnrn®) 2020 Candidate Handbook. Chicago, IL: The American Board of Neuroscience

Nursing.

YMCA of Delaware. (2020, April). Retrieved from https://www.ymcade.org/