Nurse Case Management Research Articles

From care in clinically complex cases to a model of integrated health and social care: The Alt Penedès Experience

Introduction: The Program of Chronic Complex Patient of the Alt Penedes (PCCPAP) faces the challenge of improving the quality of care to this patient profile. It determine collaborative and proactive care strategies, which are directed at adapting the use of the health and social care resources. Location:The Health District of the Alt Penedes (CataloniaSpain) has a population of 97.000 inhabitants and several health and social service providers. In 2010, the health care of CCP was fragmented, with a recurrent and high-frequency use of health emergency, hospital and community service. It was a determining factor to prioritize the health care to Heart Failure (HF) and Chronic Obstructive Pulmonary Disease (COPD) patients. Objectives:To provide integrated health care to CCP in community environment, promoting maximum autonomy within the individual situation of complexity and dependence. Identification of population target and organizations implied (stakeholders):Initially CCP were identified through a predictive model of hospital re-admissions. At the present time the classification system used is Clinical Risk Group (CRG): CRG 6 to 9 with hospital admissions and long term-care during the last year. Along side the clinical criterion of the health care professionals. PCCPAP is integrated by the three suppliers of health care of the territory (Primary Care, Hospital and Long-term care) and two providers of social services. 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 1 International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-116973 – http://www.ijic.org/ Timeline: 20102011: design of the program, agreements and pathways in health care environment. 2011-2012: implementation in HF patients with comorbidities; evaluation of results and economical impact (16 months activity, N 149). 2012-2013: incorporation of COPD patients; evaluation 28 months later, (N 290). 2013-2014: incorporation of other chronic pathologies (N 768); implementation in the home care clinical team; agreements with the 7x24 service. Agreements with social services (pending evaluation on December 2014). Highlights:PCCPAP reorients the existing resources, developing specific devices for the health care of CCP: A Day Hospital Unit for exacerbations of HF and COPD, a Case Management Unit (case manager nurses and social workers) by ensuring the continuity of care and managing resources. Agreement of clinical pathways that prioritize access to resources in a personalized way. Elaboration of Integrated Care Pathways. Development of a computer platform to share information amongst all professionals involved. Impact and results:Evaluation results at 28 months: N= 290. 91% of CCP including CRG 6 and 7. Average age 81 years, 41% are women. The cumulative mortality rate is 26%. The functional situation does not change, except Barthel Index. Increase of the use of Primary Health Care resources. Reduction of hospital admissions (Initially vs 28 months later): percentage of CCP visited in Emergency department (84.6% vs 52.4%) and hospital admissions (70.5% vs 42.8%). Conclusions: Results show a favourable trend in reduction on the use of specialized health care resources and the adequacy of the use of primary care resources. The proactive care is efficient to control exacerbations and complications, allowing to adapt the resources to patient profile of clinical and social complexity. Learned lessons: The integral and integrated approach between health and social care levels of CCP is a challenge for professionals, which requires time, training and periodic evaluations to guide the consolidation of efficient strategies.

Nursing case management, peer coaching, and hepatitis a and B vaccine completion among homeless men recently released on parole: randomized clinical trial.

Although hepatitis A virus (HAV) and hepatitis B virus (HBV) infections are vaccine-preventable diseases, few homeless parolees coming out of prisons and jails have received the hepatitis A and B vaccination series. The study focused on completion of the HAV and HBV vaccine series among homeless men on parole. The efficacy of three levels of peer coaching (PC) and nurse-delivered interventions was compared at 12-month follow-up: (a) intensive peer coaching and nurse case management (PC-NCM); (b) intensive PC intervention condition, with minimal nurse involvement; and (c) usual care (UC) intervention condition, which included minimal PC and nurse involvement. Furthermore, we assessed predictors of vaccine completion among this targeted sample. A randomized control trial was conducted with 600 recently paroled men to assess the impact of the three intervention conditions (PC-NCM vs. PC vs. UC) on reducing drug use and recidivism; of these, 345 seronegative, vaccine-eligible subjects were included in this analysis of completion of the Twinrix HAV/HBV vaccine. Logistic regression was added to assess predictors of completion of the HAV/HBV vaccine series and chi-square analysis to compare completion rates across the three levels of intervention. Vaccine completion rate for the intervention conditions were 75.4% (PC-NCM), 71.8% (PC), and 71.9% (UC; p = .78). Predictors of vaccine noncompletion included being Asian and Pacific Islander, experiencing high levels of hostility, positive social support, reporting a history of injection drug use, being released early from California prisons, and being admitted for psychiatric illness. Predictors of vaccine series completion included reporting having six or more friends, recent cocaine use, and staying in drug treatment for at least 90 days. Findings allow greater understanding of factors affecting vaccination completion in order to design more effective programs among the high-risk population of men recently released from prison and on parole.

Musculoskeletal pain in melancholic and atypical depression

Objective. Pain and depressive disorders often present together, but little is known about the prevalence of pain in depression subgroups. The objective of this study was to examine the possible differences in the prevalence of musculoskeletal pain between participants in melancholic and atypical depression subgroups. Design. Cross-sectional study. Setting. Depression nurse case managers where depression patients receive treatment in primary health care. Subjects. Participants included 413 depression patients and 401 controls. Methods. Depressive symptoms were determined with the Beck Depression Inventory (BDI-21), and diagnosis of depression was confirmed with the Mini-International Neuropsychiatric Interview (MINI). The participants were dichotomized into subgroups with melancholic depression (n = 269), atypical depression (n = 144), and controls (n = 401). Musculoskeletal pain was identified during last four weeks. Participants were enrolled in the study between 2008 and 2009. Results. The prevalence of pain was 37% in controls, 57% in atypical depression, and 71% in melancholic depression ( P < 0.001, after adjusting for sex and age). A logistic regression model showed that the odds ratio of pain after adjusting for confounding factors was 2.35 (1.56 to 3.56) with atypical depression compared with controls ( P < 0.001) and 4.38 (3.03 to 6.33) with melancholic depression compared with atypical depression ( P = 0.006). BDI scores were higher for those with melancholic depression than for those with atypical depression ( P < 0.001). Conclusions. Melancholic depression showed to be associated with a higher prevalence of musculoskeletal pain in comparison with atypical depression. This finding highlights the need for further studies about the mechanisms behind the association, particularly in melancholic depression.

PHS151 - Impact of case management Nurses on cancer Patients: a Systematic Review

PHS151 - Impact of case management Nurses on cancer Patients: a Systematic Review

Diabetes nurse case management: Improving glucose control: 10 years of quality improvement follow-up data

The purpose of this retrospective case-control review is to determine the effectiveness of a registered nurse case managers (RNCMs) certified diabetes educator (CDE) quality improvement case management program. RNCMs have a long tradition of providing chronic care intervention, particularly for the high-risk diabetes population with glycosylated hemoglobin (A1C) of 9% or more. However, limited data are available with regard to evaluation of such programs in a Veterans Health Administration population. ResultsA large population (N=3956) of high-risk veterans with a baseline A1C of 9% or more (mean=10.6%) was seen by the RNCM's. Paired T-tests of A1C after the last RNCM visit showed a statistically significant A1C reduction (p<0.001) (mean=8.5%), after 14–26 months of intervention. ConclusionsRNCMs clinical intervention demonstrated significant A1C reduction (~2%). This is an important finding for health care policy makers for planning interventions with respect to long-term management of diabetes mellitus.

A nurse-led case management program on home exercise training for hemodialysis patients: A randomized controlled trial.

Patients on maintenance hemodialysis suffer from diminished physical health. Directly supervised exercise programs have been shown to be effective at improving physical function and optimizing well-being. However, nurses seldom include an exercise intervention in the care plan for hemodialysis patients. The purpose of this study was to examine the effects of a 12-week nurse-led case management program on home exercise training for hemodialysis patients. The study was a randomized, two-parallel group trial. Hemodialysis units in two tertiary hospitals in Nanjing, mainland China. One hundred and thirteen adult patients who have been in stable condition while on dialysis treatment for more than 3 months were recruited and randomly assigned to either the study group (n=57) or the control group (n=56). Both groups underwent a brief weekly in-center exercise training session before their dialysis sessions for the first 6 weeks. The study group received additional nurse case management weekly for the first 6 weeks and biweekly for the following 6 weeks. The intervention was to facilitate patients in performing regular exercise at home. Outcome measures, including gait speed, 10-repetition sit-to-stand performance, and quality of life were collected at baseline, and at 6 and 12 weeks into the program. The results revealed that patients in the study group demonstrated greater increases in normal gait speed [F(1,111)=4.42, p=0.038] than the control group. For the study group, a mean increase of 12.02 (±3.03)centimeters/second from baseline to week 12 was found. With regard to the fast gait speed, there was a marginally significant between-group effect [F(1,111)=3.93, p=0.050]. The study group showed a mean improvement of 11.08 (±3.32)cm/s, from baseline to week 12. Patients from both groups showed improvements in their 10-repetition sit-to-stand performance. The between-group differences approached significance [F(1,111)=3.92, p=0.050], with the study group showed greater improvement than the control group. The time taken by the patients in the study group to complete the 10-STS test increased by 5.75 (±3.88)s from baseline to week 12. Significant improvements in quality of life across three time points were found only in the study group. Home exercise using a nurse-led case management approach is practical and effective in improving the physical function and self-perceived health of stable hemodialysis patients.

Food insecurity and effectiveness of behavioral interventions to reduce blood pressure, New York City, 2012-2013.

IntroductionFood insecurity is associated with diet-sensitive diseases and may be a barrier to successful chronic disease self-management. To evaluate the impact of food insecurity on blood pressure reduction in a pilot clinical trial, we tested the effectiveness of 2 behavioral interventions for hypertension in people with and without food security.MethodsA group of 28 men and women with type 2 diabetes and uncontrolled hypertension were randomized to either 1) home blood pressure telemonitoring alone or 2) home blood pressure telemonitoring plus telephone-based nurse case management. The primary outcome was 6-month change in systolic blood pressure.ResultsThe 2 interventions resulted in modest, nonsignificant blood pressure reductions. Food-secure patients experienced clinically and statistically significant reductions in blood pressure, whereas no significant change was seen among food-insecure patients.ConclusionScreening for food insecurity may help identify patients in need of tailored disease management interventions.

Abstract T P341: Transitions of Care: Increasing Follow-up and Decreasing Readmission Rates After Hospitalization for Acute Ischemic Stroke

Background: Acute ischemic stroke accounts for nearly 800,000 inpatient hospitalizations annually in the United States. Post-discharge disposition varies greatly among stroke survivors. The transition to home or nursing facilities post-hospitalization provides an opportunity to improve quality of life; but also increases the potential for miscommunication between patients, care givers, and health care providers. This may result in the need for hospital readmission, which further complicates patient care. A timely post-discharge neurology clinic visit would be the ideal forum to address miscommunication and reduce readmission. Without dedicated infrastructure, it is difficult to see patients quickly, resulting in a poor follow-up rate. Our Stroke Center sought to improve transitions for stroke survivors with the addition of a neurology nurse case manager, creation of a targeted post-discharge plan, and implementation of the Bayview Stroke Intervention Clinic (BaSIC). Methods: Beginning in September 2013, all patients admitted with acute ischemic stroke were assessed by our case manager prior to discharge and a specific post-discharge plan was developed including a plan for follow-up within 4-6 weeks. This was achieved with the implementation of a weekly neurology clinic dedicated to post-stroke care, staffed by two cerebrovascular neurologists. To gauge the effectiveness of our intervention to improve follow-up rates and decrease hospital readmissions, we retrospectively compared stroke patients discharged in fiscal year 2013 (prior to implementation) to those discharged in 2014. Annual readmission rates as well as follow-up rates in neurology clinic at 30, 60 and 90 day post-discharge intervals were assessed. Results: With implementation of targeted post-discharge planning and BaSIC clinic, the 30 day follow-up rate (2.6% pre versus 8.4% post; p=0.01), 60 day follow-up rate (8.3% pre versus 16% post; p=0.01), and 90 day follow-up rate (14.4% pre versus 20.6% post; p=0.10) all improved. Hospital readmissions fell from 10.5% to 8.7% (p=0.63). Conclusion: Implementation of a targeted post-discharge plan and specialized stroke follow-up clinic decreases readmissions and increases follow-up visits with neurology.

Exploring the effect of at-risk case management compensation on hospital pay-for-performance outcomes: tools for change.

Acute care nurse case managers are charged with compliance oversight, managing throughput, and ensuring safe care transitions. Leveraging the roles of nurse case managers and social workers during care transitions translates into improved fiscal performance under the Affordable Care Act. This article aims to equip leaders in the field of case management with tools to facilitate the alignment of case management systems with hospital pay-for-performance measures. A quality improvement project was implemented at a hospital in south Alabama to examine the question: for acute care case managers, what is the effect of key performance indictors using an at-risk compensation model in comparison to past nonincentive models on hospital readmissions, lengths of stay, and patient satisfaction surrounding the discharge process. Inpatient acute care hospital. The implementation of an at-risk compensation model using key performance indicators, Lean Six Sigma methodology, and Creative Health Care Management's Relationship-Based Care framework demonstrated reduced length of stay, hospital readmissions, and improved patient experiences. Regulatory changes and new models of reimbursement in the acute care environment have created the perfect storm for case management leaders. Hospital fiscal performance is dependent on effective case management processes and the ability to optimize scarce resources. The quality improvement project aimed to further align case management systems and structures with hospital pay-for-performance measures. Tools for change were presented to assist leaders with the change acceleration process.

Does Nurse Case Management Improve the Health Care Outcomes of Patients with Non-Communicable Diseases (NCDs)! - A Narrative Review

Does Nurse Case Management Improve the Health Care Outcomes of Patients with Non-Communicable Diseases (NCDs)! - A Narrative Review

Opportunities for Social Workers in the Patient Centered Medical Home

The Patient Centered Medical Home (PCMH) has been hailed as one method of improving chronic care outcomes in the United States. A number of studies have underscored the importance of the social work role within the PCMH, yet little existing research explores the social worker as a driver of improved patient care. The Pennsylvania Chronic Care Initiative was created with a primary goal of increasing the number of practices that were recognized as PCMH by the National Committee for Quality Assurance. This article describes findings from in-depth qualitative interviews with representatives from seven primary care practices, in which the authors examined barriers and facilitators to implementation of the initiative. Barriers to implementation included small practice size, payer-driven care, not having a strong physician champion, variability within patient populations, and high implementation costs. Facilitators included having a social worker coordinate behavioral health services, clinical nurse case managers, preexisting models of outcomes-driven care, and being part of an integrated health delivery and financing system. Recommendations strengthening the role of medical social workers in primary care practices are discussed.

New models for chronic disease management in the United States and China

In the United States (US) the role of the general practitioner in primary care is changing rapidly as the team leader in the new “Patient-centered Medical Home” model of care that is designed to improve the management of chronic disease. The “Collaborative Care Model” is an integrated model of treating multiple medical and behavioral conditions. These new approaches include a nurse case manager who serves as the key point of contact to provide education, facilitate treatment adherence, and guide the patient to improvements in nutrition and physical activity that cause obesity and chronic disease. A gap analysis was conducted comparing the US and Chinese general practitioner models for providing care to patients with chronic diseases. The results of the analysis were used to make recommendations for adding components of these models that are feasible and effective for Chinese general practitioners in community health centers.

Patient-clinician mobile communication: analyzing text messaging between adolescents with asthma and nurse case managers.

With the increasing penetration of digital mobile devices among adolescents, mobile texting messaging is emerging as a new channel for patient-clinician communication for this population. In particular, it can promote active communication between healthcare clinicians and adolescents with asthma. However, little is known about the content of the messages exchanged in medical encounters via mobile text messaging. Therefore, this study explored the content of text messaging between clinicians and adolescents with asthma. We collected a total of 2,953 text messages exchanged between 5 nurse case managers and 131 adolescents with asthma through a personal digital assistant. The text messages were coded using a scheme developed by adapting categories from the Roter Interaction Analysis System. Nurse case managers sent more text messages (n=2,639) than adolescents with asthma. Most messages sent by nurse case managers were targeted messages (n=2,475) directed at all adolescents with asthma, whereas there were relatively few tailored messages (n=164) that were created personally for an individual adolescent. In addition, both targeted and tailored messages emphasized task-focused behaviors over socioemotional behaviors. Likewise, text messages (n=314) sent by adolescents also emphasized task-focused over socioemotional behaviors. Mobile texting messaging has the potential to play an important role in patient-clinician communication. It promotes not only active interaction, but also patient-centered communication with clinicians. In order to achieve this potential, healthcare clinicians may need to focus on socioemotional communication as well as task-oriented communication.

Cardiometabolic risk factors in patients referred to depression nurse case managers

Background: Disturbances in lipid and glucose metabolism are associated with depressive symptoms, and may increase suicidal behavior. Aims: To investigate the prevalence of cardiometabolic risk factors, severity of depressive symptoms, and suicidal thoughts and previous attempts in patients referred to depression nurse case managers. Methods: Blood cholesterol, triglyceride and glucose levels, depressive symptoms and suicidality were studied in 706 depressed participants and 426 controls. In addition, we compared the Beck Depression Inventory (BDI) with a diagnostic interview. Results: 448 (63%) of the patients scoring ≥ 10 on BDI had major depression or dysthymic disorder, 258 had an anxiety or alcohol use disorder, 137 (19%) had two or more diagnoses in the Mini-International Neuropsychiatric Interview. Suicidal thoughts (49%) and previous suicide attempts (16%) were more common in patients with depressive disorders. Patients diagnosed with depression had highest BDI scores and higher blood glucose levels measured at baseline and at 2 h in the oral glucose tolerance test (OGTT). Both patient groups also had higher triglyceride levels compared with the controls. In addition, metabolic syndrome and type 2 diabetes were most common among the depressed participants. In the whole study population, levels of low-density lipoprotein-cholesterol as well as baseline and 2-h blood glucose in OGTT were higher among patients with suicidal behavior. Conclusions: Cardiometabolic risk factors and metabolic syndrome are common in patients with depression, and in patients with anxiety and alcohol use disorders. The results imply that disturbance in glucose metabolism may be associated with suicidal thoughts and previous attempts.

Evidence-based nurse case management practice in community health.

The purpose of this study was to investigate and compare the type of nurse case managers' (NCMs') practice on patients' quality outcomes in community settings. Nurse case management (CM) practice with NCMs in community-based settings. The design of this study was an exploratory, descriptive secondary analysis of 4 types of service by 11 NCMs, delivered to selected Medicare beneficiaries in community settings. Descriptive statistics and ANOVA tests were calculated. The majority of CM services were delivered in home care services in the community. Most of the 4 types of services-home, telephone, clinic, and mixed care-positively changed patients' quality measure outcomes-self-care activities of daily life, quality of life, and well-being. However, there were no modes that were statistically significant in patients' quality measure outcomes at the p < .05 level in the 2-year time frame. It is imperative to know the most effective and efficient types of CM services in community health for evidence-based NCMs practice. The results contribute to understanding how community health nurses may choose to select home care interventions for effectiveness. Thus, NCMs' practice needs to be capitalized on by practicing health administrators for health care management services within the current dynamic health policy environment.

Care coordination: a model for the acute care hospital setting.

To evaluate a patient care delivery model (PCDM) that redefined roles for unit-based nurse case managers and RNs to streamline care coordination processes. Aligning care coordination in acute care is essential to meet constructs of accountable care. A pre-post descriptive study design was applied to evaluate implementation of a PCDM in an acute care hospital setting. Regression and correlation analyses were used to compare length of stay (LOS), readmissions, patient satisfaction, quality measures, and cost of care. There was a significant decrease in LOS and negative patient responses related to nurse communication in the pilot PCDM unit as compared with the control unit. The model was supported as effective and will be implemented in other units in this hospital and across the healthcare system. A unit-based nurse care coordinator role is essential to facilitate interprofessional care coordination.

Evidence-Based Nurse Case Management Practice in Community Health

Evidence-Based Nurse Case Management Practice in Community Health

Introducing case management for people with dementia in primary care: a mixed-methods study.

Case management may be a feasible solution to the problem of service fragmentation for people with dementia. To adapt a US model of primary care-based case management for people with dementia and test it in general practice. Mixed-methodology case studies of case management implementation in four general practices: one rural, one inner-city, and two urban practices. Practice nurses undertook the case manager role in the rural and inner-city practices, and were allocated one session per week for case management by their practices. A seconded social worker worked full time for the two urban practices. Participants were community-dwelling patients with dementia who were living at home with a family carer, and who were not receiving specialist care coordination. Case study methods included analysis of case loads and interviews with patients, carers, local NHS and other stakeholders, and case managers. Measures included numbers of patients with dementia and their carers, number of unmet needs identified, and actions taken to meet needs. Case manager records were compared with findings from interviews with patients and carers, and with other stakeholders. The number of eligible patients was smaller than expected. No practice achieved its recruitment target. Researchers identified more unmet needs than case managers. The practice nurse case managers reported lack of time and found research documentation burdensome. Patients and carers were positive about case management as a first point of contact with the practice, as a 'safety net', and for creating a one-to-one therapeutic relationship. Further investigation is required before case management for people with dementia and their carers can be implemented in primary care.

The evolution of case management for service members injured in Iraq and Afghanistan.

In this article we describe the nursing care needs of wounded service members (WSMs) from the wars in Iraq and Afghanistan and the evolving role of the nurse case manager (CM). New types of injuries, in-field treatment, immediate transport to multiple care centers, and new technologies have created a new patient population of WSMs that requires new types of nursing care and knowledge. We interviewed 235 nurses, including CMs from nine military treatment facilities (MTFs) and the Veterans Administration (VA), on actual patient care experiences and new knowledge development, and 67 WSMs about their experiences of care. New military and VA nurse case management roles are essential for the effective functioning of the evolving, highly specialized, and transport-based health care system. Working effectively with WSMs required that the CM role be expanded beyond health care management to include family support, re-entry, and life coaching for the extremely altered life circumstances of WSMs.

67 * Cardiac physiologists can lead in safer care for patients demonstrating atrial fibrillation

Introduction: One-third of people experiencing atrial fibrillation (AF), remain undetected due to being asymptomatic and still attract a six-fold increased risk of stroke. Using the internationally endorsed CHA2D-VASc risk score calculation, traditionally employed by physicians, patients were observed with asymptomatic AF in the cardiac physiology-led device clinic, who could be better protected for stroke. If Allied Health Professionals (AHPs) could provide comparable results to cardiology consultants, this could support earlier diagnosis of AF and referral for anticoagulant therapy, leading to safer care for patients with asymptomatic AF. Methods: The responders from the initial 28 participants were, five cardiology consultants, four nurse case managers and seven cardiac physiologists. They applied the CHA2DS2-VASc risk score to five standardised case studies, which mirrored typical data from patients with AF. Results: This prospective study demonstrated that risk score data did not vary significantly from the gold standard to the AHP participants P<0.001. There was a strong agreement between the professions. Conclusions: Prompt identification of AF and early referral for appropriate management are crucial to ameliorate the effects of this condition both physically and financially across the population. These results determine AHPs present comparable outputs as cardiology consultants, demonstrating an early opportunity to provide safer care for patients demonstrating AF in the cardiac device clinic.