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Column: Community Nurses — An Old Approach Is Back Again in the Upper Valley

Sunday, November 30, 2014
Pushed aside by the modern reimbursement-obsessed health care system, a community-based approach that flourished as far back as the mid-19th century in the Upper Valley is taking hold in the region town by town and helping older residents to remain in their homes and stay independent. Its energy comes from churches and informal groups of volunteers who are adding a health professional to the mix of existing informal networks of people aiding neighbors as they age in place.

Across the United States there are more than 38,000 “parish nurses” or community nurses, licensed clinicians with deep roots in the communities they serve. They don’t perform hands-on nursing care and aren’t under supervision of a physician. The customary credentials are a bachelor’s or higher degree in nursing, licensure by a state professional governing body and at least five years experience in clinical nursing, plus solid connection to the communities where they work.

Community health nurses play several roles. They can be health educators to the broad community and counselors to individuals dealing with health issues. They often serve as referral agents and advocates, marshaling community resources to assist individuals and families managing illness and helping family, friends, facilities and primary health resources find the best interventions for managing illness and encouraging healing.

While community nursing is strong in many parts of the United States, it has only recently begun to gain much traction in New Hampshire and Vermont. Here in the Upper Valley, the concept started with discussions at the United Church of Christ in Hanover several years ago about how the church could expand and strengthen its mission of pastoral care. With a sizable percentage of older people in the congregation, the idea of having a parish nurse become part of this mission soon emerged and was pushed forward by the Rev. Carla Bailey, the church’s senior pastor.

That led to the appointment of Ann Bradley, a member of the congregation with a deep background in nursing and experience with Good Beginnings of the Upper Valley, an outreach program for new mothers. Bradley’s success in building the parish nurse concept began to attract interest in other communities, notably Lyme, where Laurie Kenton developed a parish-community nurse structure.

Then came the Upper Valley Community Nursing Project, a collaboration based at Alice Peck Day Hospital that drew Dr. Dennis McCullough of Norwich and Laurie Harding of Lebanon together to create awareness of the benefits of community nurses and help the region’s towns build and maintain successful community nursing enterprises. McCullough is a physician/geriatrician and writer on health care policy, while Harding is a nurse with extensive clinical and teaching experience who was also a go-to authority in Concord on health care matters during several terms in the New Hampshire legislature.

UVCNP stands ready to help wherever there’s interest and is currently engaged with groups in several towns that are discussing starting community or parish nursing programs. Besides Hanover and Lyme, programs are well underway in Bradford and Hartland, and getting off the ground in the Eastman community in Grantham. Discussions have begun in the Plainfield-Cornish area and other towns are making inquiries.

How Hartland got its community nursing project rolling is illustrative. A retired social worker, Marie Curran, spearheaded the effort with support from the town’s Unitarian-Universalist and Congregational churches. Curran saw that many older Hartland people wanted to be able to “age in place” in their own homes rather than go to assisted living or retirement communities or nursing homes.

Volunteers were lined up and funds sufficient to hire a part-time nurse for the first year were raised. The effort proved popular enough that Hartland voters the following year were willing to approve a modest appropriation to help keep it rolling. From the outset, the services were to be available to all town residents without a fee.

A century and a half ago Vermont and New Hampshire towns commonly had individuals who took the lead in rallying the community to help individuals and families beset with illness. This tradition would become more formal in the early 20th century as medical knowledge expanded and the public became aware of better ways to deal with sickness. One expression of this trend came from the New Hampshire Grange movement, which successfully advocated for creation of the position of school nurse and later, in some counties, of maternity nurse.

Early school nurses rode from one-room school to one-room school to educate and advocate for what was then commonly called hygiene and included topics ranging from providing clean drinking water to the value of regular bathing. In a time when most babies were born at home, maternity nurses called on new mothers to help them get their infants off to a healthy start.

Such nurses in both states led the way to town and district nurses whose mission was education, advocacy and problem solving — never performing clinical services. This system would prevail until the 1970s, when visiting nurse agencies were being formed to provide clinical-type nursing services in the home that would enable shorter hospital stays for patients. VNA services were reimbursable through Medicare and other payment mechanisms and eventually health care outside of institutional settings would become dominated by both for-profit and not-for-profit entities tied to fees they collect from insurers.

Town and district nurses soon began to disappear under this new regime with its rigid and highly centralized structures and a void in health care would open rapidly. Patients were being discharged from hospitals equipped with prescription slips for drugs, but until they returned for a follow-up appointment, often nobody was checking to see if the medications were actually being taken as prescribed. An elderly patient living alone might have given up a nutritious diet because there was nobody coming into the home and performing a “refrigerator biopsy” to determine what she was actually eating and to steer her on a more healthy course.

Concerns about how this was playing out would lead to the renaissance of community and parish nursing across the country and convince leaders like Dennis McCullough and Laurie Harding that something can and should be done to bring it to the Upper Valley.

It doesn’t happen fast — it took the Hartland program a year to get off the ground and it’s taken four years for the Upper Valley Community Nursing Project to get where it is currently. Town activities and politics have to move at their own pace.

But when local police and fire departments, clergy, selectmen, welfare officers and neighbors need somebody to turn to and there’s a community or parish health nurse there to do home visits, teach, coach, coordinate services and promote health for individuals and the community, everyone wins.

As McCullough says: “This effort is reinjecting community care into areas that the health care system has abandoned.”

Steve Taylor lives and farms in Meriden and contributes occasionally to the Valley News.

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