Heart-Healthy and Stroke-Free: A Social Environment Handbook

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Chapter Two: Social Environment—Preventive and Medical Services

Chapters Introduction Chapter 1: Getting Started Chapter 2: Preventive and Medical Services Chapter 3: Heart-Healthy Living Chapter 4: Quality of Life Chapter 5: Direct Observations and Windshield Surveys Chapter 6: Photography and Videography Chapter 7: Key Informant Interviews Chapter 8: Library Resources and Newspapers Chapter 9: Searching the Internet Chapter 10: Worksheets Chapter 11: Heart Disease and Stroke Resources

Preventive and medical services contribute to heart-healthy and stroke-free communities in several important ways. One obvious contribution is by treating people with diagnosed heart disease or stroke. Health care services that are available, accessible, affordable, convenient, coordinated, and friendly will help ensure the best possible long-term prognosis for people who have heart disease or who already have survived a heart attack or stroke.

Health care services are also important for primary prevention of heart attacks and strokes, through the clinical management of important risk factors such as high blood pressure, high blood cholesterol, cigarette smoking, obesity, and diabetes.

In this section of the handbook, we first briefly review the contribution of several types of preventive and medical services to creating heart-healthy and stroke-free communities. Second, we list important questions about preventive and medical services for you to investigate in your community. These questions are organized into a table below.

Next, we provide three worksheets to help you get started. The worksheets include recommendations about practical methods, space for you to record your findings, and a summary table with space for you to record the assets, strengths, needs, and challenges of your community. Blank worksheets that can be photocopied can be found in Chapter 10.

Finally, a sample community assessment of preventive and medical services is included here. You will be able to see how we applied various practical methods to gather useful community information, and how we recorded and summarized that information on the forms. Sample worksheets are below.

Preventive Programs and Services

Preventive programs and services are important potential influences on heart disease and stroke at a broad community level. Preventive programs and services sometimes focus on a single risk factor for heart disease and stroke. Some examples include programs addressing smoking cessation, weight loss, physical activity, and stress management. Prevention programs related to nutrition and diet are discussed in the next section, Nutrition and Dietetics.

Screening programs for common biomedical risk factors, such as high blood pressure, diabetes, and high cholesterol, can also be considered preventive services, since these programs may identify treatment needs of people who would not otherwise have been diagnosed.

The preventive programs and services that are available in a community may vary widely in quality and efficacy. For example, in the area of smoking cessation, specific model programs have been shown to be effective through rigorous program evaluation. However, not all smoking cessation programs adhere to evidence-based protocols and guidelines.

Preventive programs and services may be offered in affiliation with several different institutions, including public health departments (both local and state), hospitals, worksites, schools, community centers, and senior centers. Important dimensions to explore for each program or service are the target population and the population served. For example, are smoking cessation services available and accessible to both women and men, of all ethnic backgrounds, income levels, and ages?

Nutrition and Dietetics

Dietary patterns and nutritional status are both very important in the prevention and treatment of heart disease and stroke. Both macronutrients (e.g., total calories and fat consumption) and micronutrients (e.g., sodium, calcium, iron, and vitamins) have been linked to the development of high blood pressure, high cholesterol, diabetes, and obesity. Professional nutrition services are a vital link in community efforts to prevent heart disease and stroke risk factors, and to manage risk conditions after they develop.

Nutrition and dietetic services related to primary prevention of heart disease and stroke may include 1) healthy meal planning for institutions such as schools, hospitals, nursing homes, and worksites; 2) nutrition education classes offered through public health departments, schools, hospitals, community centers, and senior centers; 3) professional nutrition counseling offered as an adjunct to primary medical care; and 4) diet planning offered through fitness and weight-loss centers.

For people who need to minimize the negative consequences of biomedical risk factors, professional nutrition services can be a critical resource. Nutritionists and registered dieticians can provide detailed nutritional assessments, weekly meal plans, and specific treatment recommendations for adults with high blood pressure, high blood cholesterol, diabetes, or obesity. These services may be offered through public health departments, primary care physician offices, specialist physician offices (such as cardiologists and endocrinologists), or more uncommonly, through private independent nutrition practices.

Primary Medical Care

Primary care providers serve a critically important role in the prevention of heart disease and stroke, through the clinical management of risk factors, particularly high blood pressure, high blood cholesterol, and diabetes. They can also influence their patients with advice about smoking cessation, weight loss, diet, and exercise. In addition, primary care providers are often the first line of care for common mental disorders such as depression. Physicians who provide primary care may be trained in internal medicine, family medicine, or gynecology. Many women receive their only primary medical care from their gynecologist.

Community residents may receive primary care from physicians and nurse practitioners in family practice or internal medicine. Availability of primary care providers varies across communities based on socioeconomic resources, population density, and other factors. Accessibility of primary care providers to community residents often depends on adequacy of health insurance coverage—which in turn often depends on the benefits offered by local employers. These socioeconomic factors are discussed further in Chapter 4, Social Environment: Quality of Life.

Specialty Medical Care

Cardiology, neurology, and endocrinology are the three medical specialties most important for heart-healthy and stroke-free communities. Physicians who are board-certified in these specialty areas are especially qualified to diagnose and treat the complicated medical conditions that often result from risk factors for heart disease and stroke. Unfortunately, not all communities have specialty medical care available. This is especially true in small towns and rural areas, where residents may have to travel many miles to a larger town or city to receive care from a specialist.

Emergency Medical Services

Emergency medical services (EMS) are a critical link in what the American Heart Association has termed the “chain of survival.” Community residents who suffer a stroke or an acute cardiac event, such as a myocardial infarction, are much more likely to survive with good quality of life if they receive prompt emergency care and transport to a hospital. While 911 emergency number access is available in most parts of the country, the characteristics, quality, and coverage of EMS vary widely among communities.

EMS are typically funded and managed through local city and county governments, often through fire departments but sometimes as separate agencies. At the local level, EMS coverage can range from highly sophisticated paramedic-staffed ambulances and first-response vehicles equipped with 12-lead electrocardiograms in major metropolitan areas to all-volunteer fire departments in rural areas, with no staff trained beyond the level of cardiopulmonary resuscitation and basic life support. For EMS to provide effective treatment for heart disease and stroke, it is important that the following conditions be in place: public awareness of the signs and symptoms for heart attack and stroke, along with the need to call 9-1-1; availability of universal, enhanced 9-1-1 coverage; EMS protocols and training for treatment of heart attack and stroke victims; and priority dispatching to hospitals that can comply with stroke treatment guidelines.

Hospitals

Inpatient care is necessary for community residents who suffer a major cardiac event or a stroke. For stroke patients, diagnostic equipment and laboratory tests are critically important to determine whether the stroke is hemorrhagic or ischemic. Stroke type must be correctly diagnosed before appropriate treatment can be provided. Patients suffering from coronary heart disease and congestive heart failure have a similar need for hospital-based diagnosis, testing, treatment, and round-the-clock monitoring of response to treatment.

Consequently, accessible hospital care is necessary for sustaining heart-healthy and stroke-free communities. Accessibility of hospital care needs to be ensured for everyone, including people with limited incomes, language or cultural barriers, or lack of personal transportation.

Coronary Care Units

Hospital-based coronary care units (sometimes called cardiac intensive care units) provide advanced 24-hour intensive care for patients recovering from heart attacks, cardiac surgery, and invasive cardiac procedures such as angioplasty. Coronary care units are typically found in tertiary care hospitals located in metropolitan areas. Because coronary care units are staffed by highly trained and specialized nurses, and by medical residents and other physicians, the quality of patient care is typically higher than in a general-service community hospital. Furthermore, the larger patient caseload allows staff to gain more experience in managing in-hospital emergencies such as cardiac arrests.

For residents of smaller towns and rural areas, the nearest hospital is typically a community hospital that does not have a coronary care unit. In these areas, medical evacuation by ambulance or helicopter is required to access a hospital-based coronary care unit. For some remote and rural areas, the nearest coronary care unit may be more than 100 miles away. However, within larger cities, access issues may also be a problem for vulnerable populations, even if several coronary care units are available at nearby hospitals.

Mental Health Care

Mental health is related to cardiovascular health in at least two ways. First, one of the most common mental disorders, depression, is a risk factor for both heart disease and stroke. Although depression is common, adults suffering from this disorder are often undiagnosed and untreated. Second, depression and other mental disorders can worsen the prognosis for adults already suffering from heart disease and stroke.

Mental health care may be available to community residents in a number of different settings. Adults can receive basic mental health screening through their family physicians or other source of primary care. In some cases, primary care physicians may prescribe antidepressant or other psychoactive drugs without further referral. Ideally, however, patients who are diagnosed with depression will be referred to a specialist for follow-up care—either a medical specialist (psychiatrist) or a psychological specialist (counselor, social worker, or psychologist).

Mental health care may also be available through public health departments, private clinics, stand-alone mental health centers, and private practices of specialists such as psychiatrists, psychologists, and social workers. Counseling services may be available through affiliated institutions such as schools, colleges, worksites, community centers, churches and synagogues, and senior centers.

Rehabilitation Services

Long-term rehabilitation services are important in helping heart disease and stroke patients recover as fully as possible and return to a fulfilling quality of life. Stroke patients may need speech therapy, occupational therapy, and physical therapy to help restore cognitive and physical functioning. Heart disease patients may need cardiac rehabilitation services such as exercise and strength training, nutrition and weight loss counseling, and support for smoking cessation and other lifestyle changes that can improve quality of life and help prevent another acute cardiac event.

Rehabilitation services are often hospital-based but may also be offered through independent medical and rehabilitation clinics. As with many types of preventive and medical services, rehabilitation services tend to be more available and accessible in larger cities and metropolitan areas than in small towns and rural areas. Communities that lack these services locally may be able to improve access for local residents by arranging for visiting service providers to be available 1 day per week, or by coordinating transportation to rehabilitation providers in nearby cities or towns.

Nursing Homes

The availability, affordability, and quality of nursing home care can have a substantial impact on health outcomes for elderly community residents. Most people in a community who are living with heart disease or who have survived a stroke are elderly. Nursing homes provide supervision and round-the-clock nursing care to elderly people who can no longer care for themselves at home. Nursing homes also provide care to people (of all ages) who are experiencing a long recuperation following major surgery or a major adverse health event such as a heart attack or stroke.

Further Reading

• Balady GJ, Ades PA, Comoss P, Limacher M, Pina IL, Southerd D. Core components of cardiac rehabilitation/secondary prevention programs: A statement for healthcare professionals from the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation Writing Group. Circulation 2000;102(9):1069–1073.
   
• Pearson TA, Bazzarre TL, Daniels SR, Fair JM, Fortmann SP, Franklin BA. American Heart Association guide for improving cardiovascular health at the community level: a statement for public health practitioners, healthcare providers, and health policy makers from the AHA Expert Panel on Population and Prevention Science. Circulation 2003;107(4):645–651.

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Planning Worksheet for Preventive and Medical Services
Choose Your Questions and Practical Methods

Use this planning worksheet and the table above to help choose the most important questions for your community. Write each question in the left-hand column. Then, focus on one or more types of service. Next, choose one or more practical methods. You can photocopy the blank planning worksheet in Chapter 10.

SAMPLE

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Results Worksheet for Preventive and Medical Services
Using During and After Your Fieldwork

Complete Results Worksheet(s) for each of your questions. Write the question at the top of the worksheet. Then, for each practical method, record your findings under “Assets and Strengths” and “Needs and Challenges.” You can photocopy the blank Results Worksheet in Chapter 10.

SAMPLE

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Summary Worksheet for Preventive and Medical Services
What Are Your Most Important Results?

Condense your findings recorded on each of your Results Worksheets to highlight the most important assets, strengths, needs, and challenges.  You can photocopy the blank Summary Worksheet in Chapter 10.

SAMPLE

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Date last reviewed: 07/09/2007
Content source: Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion