It takes a village: a community partnership model in caring for the homeless.

Population health management calls for hospitals and health care entities to better align their strategies in order to deliver quality care more efficiently. Although these efforts tend to be addressed with insured populations, the homeless demand a very intentional focus. The issue of homelessness has adverse effects on the health care system, resulting in the inefficient use of resources. Community-wide efforts must be mobilized to address this inefficiency and need for preventative care and self-management education for this population. Carondelet Health Network, in partnership with El Rio Community Health Center, a federally qualified health center, along with other health care and social service providers, has established the Southern Arizona Health Village for the Homeless, providing a health care delivery system to ensure the best functional and clinical outcomes. This system includes a van (the Van of Hope), licensed as a health center, and staffed with an El Rio Community Health Center nurse practitioner and a medical assistant partnering with a Carondelet Health Network behavioral health specialist and a community outreach worker. Clinical patient information is managed via an electronic health record inclusive of clinical data, number of visits, referrals, self-management education, hospitalizations, and follow-up care. A post-hospital program with shelters and an Emergency Room Navigation Program are additional components of the village that provide a comprehensive pre-acute and post-acute effort to support the homeless. Financial impact is measured by reductions in hospitalizations and average length of stay.

Self-management of chronic kidney disease.

Living with chronic kidney disease usually involves management of other chronic conditions, such as diabetes or hypertension, and often requires a change in the patient's way of life: medical and emotional aspects of the disease must be handled, symptoms interpreted and reported, partnerships with health care providers forged, and new resources used. Nurses can help patients maneuver this initially frightening and sometimes difficult terrain with strategies tailored to the stage of the disease.

Reliability and validity of a risk assessment tool for patients with kidney failure.

Reliable and valid tools are needed to assist nurses to prospectively identify high-risk patients with kidney failure. Early identification of high-risk patients permits targeting of nursing interventions and resources to improve quality and cost outcomes. A 16-item risk assessment tool Risk for Outcomes Adverse to Dialysis (ROAD), was developed based on a comprehensive review of the literature on risk factors associated with adverse outcomes with kidney failure Reliability and validity of the ROAD was tested on a random sample of 253 participants in the Anemia Management Demonstration Project. High risk scores on the ROAD were significantly associated with hospitalization 1 to 6 months following risk assessment and inversely correlated with physical and mental components of quality of life. The results indicate that the ROAD provides a useful tool to identify patients on hemodialysis at risk of poor outcomes.

The power of dialogue with the Global Nursing Exchange.

The Global Nursing Exchange is a welcoming, unstructured environment that connects colleagues in deeper ways. Nurses from a variety of environments dialogue about what could be and how to create it. Discussions are affirming, confirming, and challenging, creating personal and professional growth and innovation.