Nurses and other healthcare providers focus on ways to educate people at their level of literacy and understanding so that patients may choose behaviors and lifestyles that promote positive health outcomes. This chapter describes components of the home healthcare setting, the populations of people who receive home health services, and roles of the home care nurse throughout every phase of home care service. The chapter begins by discussing ways in which levels of prevention can be used to gauge a person’s status along the continuum from health to illness and what their needs may be at home. In addition, the chapter addresses healthcare rendered in rural areas, including the healthcare challenges faced by people living in remote parts of the country. Last, the chapter describes issues that arise during transitions of care from one setting to another.

The work of nurses in managing and advancing population health is not complete without advocacy actions and contributions to policy making. This chapter focuses on the concepts, skills, and activities related to advocacy and policy making that are important to nurses to support and advance population health goals. Knowledge of the social determinants of health aids nurses in understanding the root causes of poor health among populations and provides guidance toward solutions. With nearly four million nurses in the United States, nurses’ civic engagement through the vote is a particularly powerful form of political participation that can have great influence over the direction of health policies. By using strong communications and advocacy skills, nurses can and should engage in advocacy and the policy process to improve the health of populations as part of their ethical professional promise to the people for whom they care.

Patient-Centered Medical Homes are models of practice that seek to improve healthcare quality and patient engagement through enhanced technology and care coordination within primary care. Use of the medical home is an approach that is patient-centered and supports patients and families by assisting them to manage healthcare decisions and involving them in their care planning. The primary care team helps patients follow their plans of care, thereby meeting their goals using coaching and advising techniques. There is also opportunity for the medical home to connect patients with peers in the community who share similar health issues and experiences to provide support and encouragement. Medical homes have infrastructure to coordinate care and provide support to patients with chronic conditions such as stroke. This chapter describes the prevalence and effects of stroke and how practicing in a medical home model can provide secondary and tertiary prevention strategies to assist in stroke recovery.

Disaster is a sudden calamitous event that brings great damage, loss, or destruction. Disasters can be categorized into three domains: natural disasters, man-made disasters, and disease outbreaks or epidemics. Disease outbreaks or epidemics include the spread of infectious diseases such as Ebola and severe acute respiratory syndrome. This chapter focuses on the effects of disasters on population health. Effective disaster risk management embodies the reduction of overall health risks and the promotion of better health outcomes across populations. Nurses are at the forefront of public health during various disasters. They can triage, prioritize, delegate, and take on leadership roles allowing for disaster response to be proactive and responsive to community needs. Disaster preparedness is essential to ensure that communities are ready to face and then recover from unexpected events that can occur. Numerous national and local agencies exist to help build community resilience.

Obesity is a health problem that affects over one third of adults in the United States. Recent data suggest that by the year 2030, over half of the U.S. population will be overweight or obese. There are multiple sequelae surrounding the epidemic of obesity. The combination of the two factors costs the United States billions of dollars in healthcare spending annually. However, chronic disease and cost are only two of the concerns related to obesity. The social determinants of culture and geography impact obesity rates and result in negative health outcomes for certain populations. There are many potential collaborative efforts available that can decrease rates of childhood obesity. Targeting children with preventive efforts can be beneficial to long-term outcomes. As such, school nurses can play a key role in these efforts, given that children spend a large portion of their day in school settings with access to the school nurse.

Heart failure (HF) is a burdensome population health issue. In the United States alone, there are over 5.7 million patients diagnosed with this disease. Currently, HF is accountable for greater than 80% of healthcare dollars attributed to treatment costs and is a considerable burden to the healthcare system. There are nonmodifiable and major modifiable risk factors that can be addressed in order to prevent this disease in specific populations. Rural America accounts for one fourth of the total population of the United States and this population has the lowest access to care. Nurses are challenged to provide quality care to these areas. Through the use of telehealth, prevention, and risk assessments, nurses can improve health outcomes of populations with HF, especially in rural areas.

Nurses have been improving the health of populations for decades. Whether they are improving the health of our children in schools or the health of individuals across a life span in primary care, they are cultivating the health of the population. Federal laws have shaped the way in which nurses provide care in the school and in primary care. Furthermore, nurses’ understanding of policies, health determinants, and health outcomes places them in the opportune position for primary, secondary, and tertiary prevention in these settings. Nurses have a unique opportunity to address emerging challenges in these settings and to shift care from reactive to proactive in order to promote health. This chapter discusses the history and evolution of school-based care and primary care, current trends, federal services available, nursing roles, and the related Healthy People 2020 objectives.

Nurses are on the front lines of U.S. healthcare, functioning in a variety of healthcare settings, specialties, and environments. Despite the alarming statistics seen from the opioid crisis, nurses can influence safe practices surrounding prescribing and monitoring patients requiring opioid therapy at all levels of prevention. As it is necessary for meeting substance use disorder and addiction challenges seen in the Veteran population, nurses must be aware of physical, psychological, and psychosocial risk factors that may place Veterans at increased risk. It is critical that nurses possess a comprehensive understanding of the role of social determinants of health, or external factors, such as socioeconomic status, education, employment, social support networks, and access to healthcare, which substantially influence health outcomes. Veterans deserve evidence-based competent and compassionate care and nurses must be the ones armed with the necessary knowledge, skills, and attitudes to take on the task of serving and caring for Veterans.

The United States is a country built on a powerful history of immigrants from all over the world. The country’s history is manifested in the assortment of cultures that currently call the United States their home. Immigrant populations have varied experiences within the U.S. healthcare system, resulting in stark contrasts in health outcomes. Disparities among marginalized and vulnerable immigrant populations exist regarding several chronic conditions, including blood pressure control. Social determinants of health such as lack of or insufficient insurance, limited language proficiency, and poverty can contribute to poorer health outcomes. The nursing role for this population includes the provision of culturally appropriate and patient-centered care services as an integral part of the solution. Through patient advocacy, education, and assistance with care access, nurses can play a significant role in reversing the negative health trends that exist among the immigrant populations.