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The American Public Health Association defines public health nursing as the "practice of promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences." In 1993, celebrating the centennial anniversary of its founding, nurse leaders recognized systemic changes have required nurses to function in clinical, illness-oriented roles rather than in their more traditional community and public health roles. With nurses' public health skills atrophying, these leaders urged members of the profession to eschew specialization and return to their generalist roots founded on the principles of community-based prevention and health promotion. Soon the Public Health Functions Project, designed in part to identify skills and curriculum needs of an array of practicing public health workers, examined the public health nursing profession. Its recommendations seek to ensure that public health nurses are trained to respond to current challenges that face public health. In this essay, we describe how a fellowship program that predated this national project by almost a decade anticipated the recommendations for shaping public health nursing by enrolling midcareer nurses in a program that taught the principles and practice of community-oriented primary care. Such principles represent a merger of clinical care with population health sciences; its more recent expressions teach clinicians to work as partners with communities to identify and address health problems. In reporting on this program, we show how nurses in practice can embrace their generalist roots, meet current challenges, and play a lead role in realizing the nation's goals for the year 2010. These aims incorporate recent recommendations for preparing public health nurses for change in the health care system.

To meet the demands of the evolving health care system, health professionals need skills that will allow them to anticipate and respond to the broader social determinants of health. To ensure that these skills are learned during their professional education and training, health professions institutions must look beyond the medical model of caring for communities. Models in Seattle and Roanoke demonstrate the curricular changes necessary to ensure that students in the health professions are adequately prepared to contribute to building Healthy Communities in the 21st century. In addition to these models, a number of resources are available to help promote the needed institutional changes.

Resource utilization in home health care has become an issue of concern due to rising costs and recent initiatives to develop prospective payment systems for home health care. A number of issues remain unresolved for the development of prospective reimbursement in this sector, including the types of variables to be included as payment variables and appropriate measures of resource use. This study supplements previous work on home health case-mix by analyzing the factors affecting one aspect of resource use for skilled nursing visits--visit length--and explores the usefulness of several specially collected variables which are not routinely available in administrative records. A data collection instrument was developed with a focus group of skilled nurses, identifying a range of variables hypothesized to affect visit length. Five categories of variables were studied using multiple regression analysis: provider-related; patient's socio-economic status; patient's clinical status; patient's support services; and visit-specific. The final regression model identifies 9 variables which significantly affect visit time. Five of the 9 are visit-specific variables, a significant finding since these are not routinely collected. Case-mix systems which include visit time as a measure of resource use will need to investigate visit-specific variables, as this study indicates they could have the largest influence on visit time. Two other types of resources used in home health care, supplies and security drivers, were also investigated in less detail.

We describe a community-oriented primary care (COPC) preventive medicine residency. Through the residency, medical, nursing, dental, and other health professionals work as fellows to combine clinical and public health skills in primary care practices. We describe the steps that fellows used to begin transforming one community health center into a COPC practice, and we highlight the activities of one specific environmental cleanliness project as an example. COPC activities have laid the foundation for further advances in developing a professional partnership between the center and the community it serves.

Investor-owned walk-in centers are a recent innovation in ambulatory care. The authors surveyed private practice primary care physicians about their marketing strategies before and after the advent of a local walk-in center. Respondents were more likely to report that they accepted walk-ins and that they advertised in the latter than in the former time period. Findings are discussed in the framework of previous predictions about the impact of walk-in centers on the delivery of care in traditional primary care practice settings.

Several aspects of quality of care at one chain of freestanding ambulatory health care walk-in centers were evaluated. Those areas for which data were available--medical record review, physician credentials, and patient satisfaction--suggest that for primary acute episodic care, HSMMI walk-in centers provided care comparable to that which would have been received in traditional health care settings. In fact, HSMMI offices were found to be similar in organizational structure and appeared very much like private physicians' offices in management, staffing, patient flow, and physician performance. The corporation's QA program evolved from a series of informal managers' meetings (in 1986), to a detailed and structured program involving a CEO and regional medical directors by the end of 1990. The exact way in which HSMMI's new emphasis on formal quality-of-care assessment and assurance will affect patient care will be seen as the program fully matures. The issue of the proper relationship between money and medicine remains a problem. As health services organizations are increasingly influenced by market forces and consumers have ever-higher expectations, patients and physicians alike want to be sure that high-quality health care remains the first priority. Although this is an issue for all providers, it is much more visible in proprietary offices, making physicians as well as the public uneasy. For this reason, HSMMI's burden of proof regarding quality may be higher--particularly within the medical community--than the burden on traditional private practice physicians.(ABSTRACT TRUNCATED AT 250 WORDS)

In sum, people go to a walk-in office for quick, convenient service, and overall they are happy with their experience. Although we cannot generalize from this case study of one chain of walk-in centers to walk-ins nationally, results from other studies of walk-in patient populations are approximately similar to ours.

This article describes physicians at a major chain of investor-owned free-standing walk-in centers and reports on their job satisfaction. They derived satisfaction from a sense of autonomy and the corporation's reliable provision of staff and supplies. Their job dissatisfaction results from the corporate emphasis on generating revenue and the lack of opportunity for professional interaction with colleagues.

Health Stop is a major chain of ambulatory care centers operating for profit. Until 1985 its physicians were paid a flat hourly wage. In the middle of that year, a new compensation plan was instituted to provide doctors with financial incentives to increase revenues. Physicians could earn bonuses the size of which depended on the gross incomes they generated individually. We compared the practice patterns of 15 doctors, each employed full time at a different Health Stop center in the Boston area, in the same winter months before and after the start of the new arrangement. During the periods compared, the physicians increased the number of laboratory tests performed per patient visit by 23 percent and the number of x-ray films per visit by 16 percent. The total charges per month, adjusted for inflation, grew 20 percent, mostly as a result of a 12 percent increase in the average number of patient visits per month. The wages of the seven physicians who regularly earned the bonus rose 19 percent. We conclude that substantial monetary incentives based on individual performance may induce a group of physicians to increase the intensity of their practice, even though not all of them benefit from the incentives.