DESCRIPTIVE TITLE OF APPLICANT'S PROJECT* INSPIRE HHC: Interactive Nursing Support to Promote Integrated Care for Elders REceiving Home Health Care

Abstract

Background: Integrated Care Management (ICM) that delivers patient-centered physical and psychosocial nursing care, produces superior health outcomes (e.g., less disability /depression/hospitalization) in older vulnerable persons who have multimorbid conditions including depression. 1-4 However, physical and psychosocial ICM is rarely found in Medicare home healthcare (HHC) settings, where the bulk of healthcare services are provided to older persons with multimorbidity. Instead, current HHC services provide care management for HHC patients short-term needs, following an acute illness, injury, or disease exacerbation,5 despite the existence of high levels of disability (40-70%), depression (40-70%) 6-10 and multiple illnesses (80%+). When multimorbidity needs are identified, the emphasis for care is placed on treatment strategies for physical health rather than ICM.9,10 This traditional service approach results in persons receiving segregated physical and mental healthcare as well as a lack of coordination between providers leading to untoward outcomes (e.g. medication errors).20-26 Yet, providing ICM to persons with multi-morbidities receiving HHC requires a uniquely different skill set for nurses.9 Thus, we developed a novel ICM education/training course, for nurses designed to provide them with skills needed to deliver ICM to their older patients to prevent disability worsening and improve psychosocial health. Design: The study used a mixed method design to develop an evidence-based hybrid online educational program. The program focused on the following 4 content areas and is informed/guided by the Chronic Care Model (CCM), ICM competencies, and expert panel (PNP, DNP, Ph.D.): (1) recognizing, treating, and providing depression care management (2) learning communication skills and developing therapeutic relationships, (3) goal setting and behavior change self-care management (4) facilitating integrated, coordinated, and interprofessional teams’ management.After development/pre-testing the course with supervisory staff, the course was pilot-tested with experienced nurses. Results: Surveys results from the pre-test by the expert panel demonstrated agreement the course was acceptable to use within the Medicare HHC reimbursement system. The panel provided useful modifications for educational content, skill building, and videos. Nurse post-test scores on module tests and comprehensive exam -showed significant improvement in knowledge and skill building scores and nurses agreed that training was useful and applicable. Lessons Learned and Suggestions for Future Research: The training curriculum showed improved nurse knowledge and skills needed to address the needs of older persons with multimorbidity and health complexity. We also found that leveraging the on-going nurse-patient relationship occurring during the HHC episode, addressed a missed opportunity to expand and enhance the therapeutic communication skills of HHC nurses’ well within their scope of practice. We will use this course as foundational part of pilot-testing a novel, nurse-supported ICM intervention, for older patients with multimorbid conditions- INSPIRE (Interactive Nursing Support to Promote Integrated care for elders REcieving HHC) designed to prevent disability worsening and improve psychosocial health. The course will be used to train intervention nurses, to ensure they have competencies to assess and provide ICM interventions that address the physical, mental and social health issues of study subjects. Thus, the ICM activities incorporated in this course have the potential to transform the way traditional HHC is practiced.