Community Project

Needs Assessment and Data Collection

The United States has dedicated efforts in eliminating and reducing disparities in healthcare. Despite these efforts, there exist significant healthcare disparities such as minority populations, access to healthcare, mortality, morbidity, and risk factor. Research studies indicate that low-income people are more likely to have poor health, have a high risk of contracting health complications (Scally & Pettit, 2017). The subpopulation to be examined in this needs health assessment is low-income population Brockton Massachusetts. These are individuals who have less access to healthcare services, do not have health coverage, and are adversely affected by medical diseases such as diabetes and obesity. Low-income populations may not have a safe place to stay, and they are at increased risks of health-related outcomes. We unfortunately find low income houses often. The main skilled need is many times not nursing needs but rather medical social worker to assist with finance, food, transportation and housing. There are many times where peoples health gets put on the back burner due to all of these other life stressors around them. Taking the time to educate about the importance of health care poxys and why they are important during a difficult time will be a hurdle to jump.

The population of Brockton is composed of 52% males and 48% females. Majority of the people are aged between 20 to 69 years (63.5%), less than 20 years (29.9%) and over 6.6%. The Whites comprise 46%, Blacks 31%, Hispanics, 9%, Asian, 2% while other groups make 12%. With a birth rate of 6%, the average household size is 2.79. The average birth weight is 7.9 while the rate of prematurity is 8.4. Major mortality disease includes cancer and heart disease. The environment is conducive for living (Collins, Knorr, & Medaglia, 2017). The Facility that I currently work for is aware of this mortality rate and has formed several different groups in hopes to educate and manage these disease processes better. In the Brockton community, we have 2 cancer centers along with a program located out of Brockton Hospital called ‘The Heart Success Clinic’ this clinic is made of of a cardiologist, NP, 2 nurses and they collaborate with the palliative team and a complex care manager weekly. They do this for many reasons but to also have a patient centered goal in which everyone is realistic about.

The area is surrounded by hills and valleys which are separated by rivers. About 10.5% of the population is unemployed and have homeless shelters. Prior to a month ago, we as a VNA were not going into homeless shelters to care for patients. We have now partnered with a hospital in which we now do. I plan to work on health care proxies and advanced directives with the patients located in the shelter. The workplaces are majorly blue collar jobs. The community also has recreational facilities such as playgrounds and public parks. The Brockton community, along with many others, have a special program for women, infants and children (WIC) for low- income postpartum, breastfeeding, and pregnant mothers. About 25.9% of the adult population is obese. As per the levels of education, about 92% are high school graduates while there are 41% who hold a bachelor’s degree or higher (Collins, Knorr, & Medaglia, 2017).

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Literature Review

In the study by Karnik and Kanekar (2016) to discuss the ethical issues surrounding end-of-life care, it was found that factors like autonomous decision making, advance directives (AD), physician’s role and responsibilities to solve the problem, rationing of care and futile treatment, and patient’s perspective and preferences can influence the quality of end-of-life care provided to patients. Patients have the right to self-determination whereby they have a say in the type of end-of-life treatment they prefer.

Although patients have the autonomy to choose treatment options, physicians are required to advise them about the benefits and shortcomings of the preferred medical interventions. Moreover, an advance directive is necessary to enable proficient persons to design and document their health care decision blueprint in anticipation of future frailty or incurable ailment. Furthermore, it is essential to weigh the cost of treatment and the chances of recovery before initiating end-of-life care. Only advanced treatment options that promise a high probability of healing should be adopted.

That said, Peicius, Blazeviciene, and Kaminskas (2017) conducted a cross-sectional survey to examine medical experts’ knowledge and preferences concerning AD. Another purpose of this study was to explore the view of health care professionals regarding the application of AD in a hospice setting in Lithuania. The study highlights that the increase in aging populace presents a significant threat to health care organizations, and this is because there will be few caregivers to look after them in the future. Hence, the necessity for AD.

Conversely, the embracement of AD by patients presents some moral dilemmas. For instance, the role of physicians is changing because making decisions on issues concerning end-of-life care is increasingly becoming patient-centered. Results from the study show that 83.3% of physicians who participated in the study had limited understanding of AD. The study also showed that over 50% of the participants preferred to express their wishes before the incidence of illness by applying an AD.

Keary and Moorman (2015) assess the characteristics of patients who discuss end-of-life care with their physicians, and the factors promoting such consultations, including trust in one’s physician and the extent of family advance care planning (FACP). The former can influence physician-patient end-of-life talks because of the comfort and agility developed by patients during such dialogues.

Furthermore, this research indicates that patients who visit their physicians regularly develop trust in them quickly. The study also demonstrates that a significant number of physicians encourage FACP in end-of-life discussions with their incurably sick patients. Besides, from the study, doctors who involve their patients in end-of-life discussions increases their chances of completing an FACP. Even so, having conversations fosters different planning strategies, either formal or informal, or both. A study by Cox, Moghaddam, Almack, Pollock, and Seymour (2011) investigates practice concerning debating and recording end-of-life care and preferred place to die in the last four weeks of life with patients and their families. From the study, a significant number of aging patients and their families participated in conversations with physicians regarding end-of-life care and preferred place to die.

However, there was no application of a systematic approach to record the conversations. Moreover, the participating physicians indicated that they faced some difficulties discussing the matters, including lack of openness on the part of the clients.


Collins, E., Knorr, R., & Medaglia, F. (2017). Massachusetts Population Health Information Tools: Tools for Community Health Needs Assessment and Planning.

Cox, K., Moghaddam, N., Almack, K., Pollock, K., & Seymour, J. (2011). Is it recorded in the notes? Documentation of end-of-life care and preferred place to die discussions in the final weeks of life. BMC Palliative Care, 10(1), 18.

Karnik, S., & Kanekar, A. (2016, June). Ethical issues surrounding end-of-life care: a narrative review. In Healthcare (Vol. 4, No. 2, p. 24). Multidisciplinary Digital Publishing Institute.

Keary, S., & Moorman, S. M. (2015). Patient–physician end-of-life discussions in the routine care of Medicare beneficiaries. Journal of aging and health, 27(6), 983-1002.

Peicius, E., Blazeviciene, A., & Kaminskas, R. (2017). Are advance directives helpful for good end of life decision making: a cross sectional survey of health professionals. BMC medical ethics, 18(1), 40.

Scally, C. P., & Pettit, K. L. (2017). How to Engage Your Community with Health Data.

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