Module 5: Community-Based Care – Home Health Nursing


(All papers must have INTRODUCTION & CONCLUSION. Use the uploaded Grading Rubric to write the paper)

This first discussion assignment is intended to help each student set a context for the course, establish expectations and goals for the course, and provide insights to the instructor enabling tailoring of the course to better fit the needs of the students. Replies to discussion questions must be well considered and scholarly. A quality initial response to the Discussion Question should be roughly 400 words. (Selected Journal article MUST not be more that 5 years old)


In this module, we will shift our focus to home health care services and the role of the nurse in providing community-based care. 

Community-based care is not a new or innovative aspect of the health care delivery system; however, it is a crucial component of the overall health care system. Time and time again, it has been demonstrated that home health care services are cost-effective in comparison to other delivery methods. Living independently at home is a priority for many individuals; and community-based care makes this possible.

As is the common theme in healthcare today, the future of home health care is challenging; but considered bright. Home health nurses have the opportunity to function in clinical or administrative capacities. Regardless of the path selected, the home health nurse is situated to lead. Leadership will be required to demonstrate that home health care services remain the most efficient, effective, and comfortable option for individuals with complex care needs residing in the community.

Goals Alignment 

University Mission Based Outcomes – 1, 2, 3, 4, 5

Program Learning Goals – 1, 2, 3, 4, 7, 8, 9

Course Learning Objectives – 1, 4, 6, 12

Professional Standards


A picture containing textDescription automatically generated Learning Materials

  • Clark, M. (2015). Population and Community Health Nursing (6th ed.). Pearson. ISBN: 9780133846584. Read Chapters 10 & 13.

Additional Resources:

  • Case Management Society of America. (2016). Standards of practice for case management.
  • ENTP Life. (2020, March 23). How to start a home care agency | Episode 1 – Getting started 7 key steps [Video]. YouTube.
  • ENTP Life. (2020, April 5). How to start a home care agency | Episode 2-researching state regulations & application process [Video]. YouTube.
  •  ENTP Life. (2020, April 19). How to start a home care agency | Episode 3-building effective teams [Video]. YouTube.
  • ENTP Life. (2020, April 22). How to start a home care agency | Episode 4-which is better corporation or LLC [Video]. YouTube.
  • ENTP Life. (2020). How to start a home care agency | Episode 7 -policies and procedures [Video]. YouTube.
  • Scope and standards of practice for registered nurses in care coordination and transition management. (2015). ProQuest Ebook Central.

Discussion Question:

Discussion Question 1: Choose one of the following prompts:

The home and community are increasing in importance as the recommended point of care delivery.  Identify a recent news article that supports this assertion. Summarize the article and discuss how this information will influence and support the patient and family in achieving the best possible outcomes while remaining in the community. Provide a link to the article you have chosen for this discussion post.


You are a home health nurse and your agency has received a referral for an elderly male with congestive heart failure. Discuss how the determinants of health (biological, psychological, environmental, sociocultural, behavioral, and health system) can influence the client’s overall health status.


Elderly Male Patient Referral Determinant

Author’s name

Department, University

Course code




                As people grow old, their health is determined by determinants such as biological, psychological, environmental, sociocultural, behavioural, and the health system. The health of the age is of great importance to public health. Therefore, elderly patients deserve quality care. The main objective of this paper is to discuss how the determinants of health influence the referral of an elderly male with congestive heart failure.

           The biological determinant that would influence the status of the elderly patient would focus on structural changes, functioning of the heart, and physicochemical properties of the cells. Moreover, age and genetic reason might have impacted the health status of the patient (O’Neil et al., 2018). From a psychological perspective, factors such as depression and anxiety contributed to the elderly man predicament (Kavalieratos et al., 2017). Environmental reasons that might have influenced congestive heart failure are air pollution and exposure to arsenic or lead (Bourdrel et al., 2017). The elderly patient might have a history of heavy consumption of alcohol and smoking, thus leading to heart failure. Other behavioural factor includes physical inactivity and unhealthy eating (Hassen et al., 2020). Reduced access to care, living in less fortunate neighbourhoods, and lack of social relationships are the social-cultural determinants that might influence the health status of the elderly male.  The health system might be at fault. Staffing Shortages, deficient facilitation and poor technology probably influenced the overall health status of the elderly male (Savarese & Lund, 2017).

               Conclusively, care for elderly patients with chronic conditions is complicated. Like in any other group, the elderly need quality care. Many determinants influence health in elderly patients with congestive heart failure. However, age, structural changes, physical reasons or psychological factors influenced the health of the elderly male.


O’Neil, A., Scovelle, A. J., Milner, A. J., & Kavanagh, A. (2018). Gender/sex as a social determinant of cardiovascular risk. Circulation137(8), 854-864.

Hassen, H. Y., Bastiaens, H., Van Royen, K., & Abrams, S. (2020). Socioeconomic and behavioral determinants of cardiovascular diseases among older adults in Belgium and France: A longitudinal analysis from the SHARE study. PloS one15(12), e0243422.

Bourdrel, T., Bind, M. A., Béjot, Y., Morel, O., & Argacha, J. F. (2017). Cardiovascular effects of air pollution. Archives of cardiovascular diseases110(11), 634-642.

Kavalieratos, D., Gelfman, L. P., Tycon, L. E., Riegel, B., Bekelman, D. B., Ikejiani, D. Z., & Arnold, R. M. (2017). Palliative care in heart failure: rationale, evidence, and future priorities. Journal of the American College of Cardiology70(15), 1919-1930.

Savarese, G., & Lund, L. H. (2017). Global public health burden of heart failure. Cardiac failure review3(1), 7.