You are employed as a clinic nurse at an Indian Health Service(IHS) facility serving a population of 4,300 tribal members on areservation. You identify that the incidence and severity ofdiabetes problems are escalating dramatically for tribal members.You note that there is a high rate of missed appointments in thediabetes clinic. You find it difficult to follow up with patientsbecause many have no telephones. Patients tell you that some oftheir difficulties getting to clinic are due to lack of reliabletransportation to the clinic and the long distance they need totravel to get there. Some patients say they don’t feel they arerespected when they do make it to the clinic. In addition, youlearn that many grandparents and great-grandparents may be unableto leave home because of child-care responsibilities for extendedfamily members. The nearest hospital and dialysis facility is over100 miles away at another IHS unit. You decide to consult with thecommunity health nurses who work for the Tribal Health Departmentto assist you in developing a plan that will lead to moreeffectively meeting the health needs of the people you serve withthe resources available regionally.
1. Describe the work skills and knowledge base you will need tofunction effectively in community-based nursing practice.
2. Explain the importance of continuity of care and dischargeplanning in the emerging healthcare system.
3. Propose how nurses will work with various sectors of thecommunity and healthcare professionals.
