Identification of Target Population and Needs Assessment


What health issue, problem, social determinant, or disparity in health outcomes is of concern to you as a new nurse and care provider in a community?

 What gaps in knowledge and care do you see as a possible cause for the health issue?

 What does the health data and literature tell you about the health issue? Include a description of the social determinants that are contributing factors.


From your Community Health Assessment assignment (RN 406) you may have noted the needs of a particular population through observation, data collection, and new knowledge.


Evidence-Based Interventions Goals with Measurable Outcomes


What evidence is there to support your proposed interventions?

 What type of change is expected? (behavior, financial, support systems, etc)

.  What is one avenue you could advocate for improved health outcomes and know when a change has taken place?

  Describe 3 evidence-based interventions from a source such as Healthy People 2030.

  Identify at least 3 measurable goals for the patient/population that are SMART (Specific, Measurable, Achievable, Realistic, and Time-bound). Identify any obstacles or barriers to assisting the patient/population to achieve the goals in your discussion. These would include the social determinants of health—economic, education, physical environment, etc.


Collaboration/Partnerships and Care Coordination with Safety-net Community Agencies/Service Organizations


Discuss the collaboration and partnership the nurse will seek for assisting the client/population over the long term.

 There may exist gaps in care and these may be addressed in part by referral to the service organization once the nurses’ role and care is complete.