prescribe medication, and create teams of providers to help manage the needs and care of patients and their families. APRNs are educated to refer patients to physicians or other providers when necessary.

Box 2-3 illustrates how one NP provides primary care both in a school, where she is required by the school district regulations to do less than she is trained to do, and in a low-cost clinic, where she may practice to the full extent of her training and licensure. Chapter 3 examines in detail why NPs, and more broadly APRNs, are often limited by regulations in the extent of the health services they may provide.

The Need to Deliver More Care in the Community

Care in the community—defined as those places where individuals live, work, play, and study—encompasses care that is provided in such settings as community and public health centers, long-term care and assisted-living facilities, retail clinics, homes, schools, and community centers. While acute care medical facilities will always be needed, the delivery of primary care and other health services in the community must grow significantly if the U.S. health care system is to be both widely accessible and sustainable (Dodaro, 2008; Steinwald, 2008).

Along with an emphasis on primary care, a key component of providing care in the community is a strong public health infrastructure to ensure the availability of a range of services that includes prevention, education, communication, and surveillance. The public health infrastructure and workforce are vulnerable and perpetually face fiscal and political barriers. As a 2002 IOM report notes, “public health infrastructure has suffered from political neglect and from the pressure of political agendas and public opinion that frequently override empirical evidence” (IOM, 2002). The public health workforce, including public health nurses, is aging rapidly. Between 20 and 50 percent of public health workers at the local, state, and national levels are eligible to retire in the next few years (ASPH, 2008; ASTHO, 2004; Perlino, 2006). Between 2008 and 2009, health departments at the local level lost 23,000 jobs—or approximately 15 percent of their total workforce—to recession-related layoffs and attrition in 2008 and 2009 (NACCHO, 2010). The number of nurses employed in public and community health settings underwent a marked decline from 18.3 percent of the RN workforce in 2000 to 15.2 percent in 2004 to 14.2 percent in 2008 (HRSA, 2010). The case study in Box 2-4 illustrates the value of nurses working in the public health sector, where many more nurses are needed.

Providing effective care in the community will require improvements in community infrastructures, resources, and the workforce. Health care providers, including nurses, will need to form new partnerships with community leaders and have strong community care–oriented competencies, such as the ability to develop, implement, and assess culturally relevant interventions.

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