Complex Chronic Care Research Articles

Community Nurse-led clinic: competence and accountability in the management of complex chronic cardiac care within the integrated Hospital-Territory network

With the progressive aging of the population, the widespread increase in chronic and degenerative diseases and the need for constant improvement in the quality of services, outpatient nursing represents a new model of community organization and management of nursing care which can respond with competence to the diverse needs of the community. Nurse-led Clinic takes care of patients with chronic heart disease (486 pts), heart failure (260 pts) and advanced heart failure (173 pts), outpatient and home management of patients with end-stage heart failure (continuous infusion of positive inotropic with portable insulin pumps, 14 pts), management of patients on oral anticoagulant therapy and new oral anticoagulants (398 pts). Across the clinics, the triage nurse takes care of patients who access the clinic through direct access or dedicated phone line for urgent assessment/monitoring of health needs. Out of 46.1% of patients who had a cardiovascular event and/or an active problem, only 1.3% was kept under observation in the ER or hospitalized. These patients had a greater hemodynamic instability that met criteria for activation of hospitalization (severe hypotension, desaturation, brady/ tachyarrhythmias, symptoms and signs of acute heart failure). The rest of the patients, with a minor instability were referred to the clinic nursing program with telephone and/or clinical follow-ups. This allows the activation of specific interventions needed to prevent hospitalization. Where necessary, local services (either district/home and/or social) are activated in order to respond to the needs expressed by the patient and his/her family. Role of Nurses: Nursing interventions are initially done in conjunction with physician's visits to provide education and counseling for patients and caregivers to improve outcomes (mortality, readmissions to hospital, hospital length of stay). Patients and/or caregivers deemed requiring specific assessment and/or support are referred to a psychologist who also provides specific training and counseling supervision allowing for a steady update and strengthening of nurses' communication and educational skills. Follow-ups vary in frequency (e.g. monthly or bi-monthly) while medical followups still tend to be scheduled quarterly to yearly according to the clinical severity of the patient. The patient's letter contains both medical and nurses' information integrating the both assessments. Conclusions: The Nurse-led Clinic may allow the improvement of health services and is a key tool for integrating hospital and community care within a health/social care framework of services which accompany the complexity of chronic care from the onset of the disease through supportive and palliative care assistance.

Diabetes in Homeless Persons: Barriers and Enablers to Health as Perceived by Patients, Medical, and Social Service Providers

The ways homelessness and diabetes affect each other is not well known. The authors sought to understand barriers and enablers to health for homeless people with diabetes as perceived by homeless persons and providers. The authors performed semistructured interviews with a sample of participants (seven homeless persons, six social service providers, and five medical providers) in an urban Midwest community. Data analysis was performed with the qualitative editing method. Participants described external factors (chaotic lifestyle, diet/food availability, access to care, and medications) and internal factors (competing demands, substance abuse, stress) that directly affect health. Social service providers were seen as peripheral to diabetes care, although all saw their primary functions as valuable. These factors and relationships are appropriately modeled in a complex adaptive chronic care model, where the framework is bottom up and stresses adaptability, self-organization, and empowerment. Adapting the care of homeless persons with diabetes to include involvement of patients and medical and social service providers must be emergent and responsive to changing needs.

Coordinated Care Management For Dementia In A Large Academic Health System

Alzheimer's disease and other dementias are chronic, incurable diseases that require coordinated care that addresses the medical, behavioral, and social aspects of the disease. With funding from the Center for Medicare and Medicaid Innovation, we launched a dementia care program in which a nurse practitioner acting as a dementia care manager worked with primary care physicians to develop and implement a dementia care plan that offers training and support to caregivers, manages care transitions, and facilitates access to community-based services. Postvisit surveys showed high levels of caregiver satisfaction. As program enrollment grows, outcomes will be tracked based on the Triple Aim developed by the Institute for Healthcare Improvement and adopted by the Centers for Medicare and Medicaid Services: better care, better health, and lower cost and utilization. The program, if successful at achieving the Triple Aim, may serve as a national model for how dementia and other chronic diseases can be managed in partnership with primary care practices. It may also inform policy and reimbursement decisions for the recently released transitional care management codes and the complex chronic care management codes to be released by Medicare in 2015.

Key factors in patient-centered care coordination in ambulatory care: Nurse care coordinators' perspectives

BackgroundCare coordination within Health Care Homes (HCHs) is an evolving registered nurse role. The purpose of this study was to identify factors influencing nurse care coordination. AimsThe aims are to 1) describe the characteristics of patients perceived by nurse care coordinators (NCCs) to benefit from care coordination and to 2) describe interventions judged by NCCs to be most effective in caring for patients with complex chronic care needs. MethodsThis study was an analysis of existing data using a qualitative descriptive design. Experienced NCCs from various practice settings participated in a focus group. Data were analyzed using content analysis. ResultsFindings indicate the importance of the cumulative impact of complex health problems, limited social support, culture and language on patients needing care coordination. Effective interventions are focused on providing holistic, relationship-based care. ConclusionThe identification of contextual factors juxtaposed to complex chronic health conditions holds promise as a powerful indicator of individuals needing targeted, individualized interventions.

APA Welcomes CMS Acceptance of Increased Work Values

APA Welcomes CMS Acceptance of Increased Work Values

Non–face-to-face Care Options in 2014

New CPT codes for complex chronic care coordination (CA), transitional care management (TCM), and interprofessional consultations for addressing overall complex health care needs

Racial and ethnic differences in clinical outcome trajectories for care managed patients.

Care management has demonstrated improvements in quality of care for patients with complex care needs. The extent to which these interventions benefit race/ethnic minority populations is unclear. To characterize race/ethnic differences in the longitudinal control of clinical outcomes for patients with complex care needs enrolled in Care Management Plus, a health information technology-enabled care coordination intervention. Multilevel models of repeated observations from clinical encounters before and after program enrollment for 6 Oregon and California primary care clinics. A total of 18,675 clinic patients were examined. We estimated multilevel models for 1481 and 5320 care-managed individuals with repeated hemoglobin A1c and blood pressure measurements, respectively. Primary outcomes were changes over time for 2 clinical markers of health status for complex care patients: (1) hemoglobin A1c for patients with diabetes; and (2) mid-blood pressure (BP) (average systolic and diastolic blood pressure). We found significant reductions in A1c for patients with previously uncontrolled A1c (preperiod slope, b=1.03 [0.83, 1.24]; postperiod slope, b=-0.63 [-0.91, -0.35]). For mid-BP we found increasing unconditional preperiod trajectories (b=3.52 [2.39, 4.64]) and decreasing postperiod trajectories (b=-5.21 [-5.70, -4.72]). We also found the trajectories of A1c and mid-BP were not statistically different for black, Latino, and white patients. These analyses demonstrate some promising results for intermediate clinical outcomes for underrepresented patients with complex chronic care needs. It remains to be seen whether these health care system delivery redesigns yield long-term benefits for patients, such as improvements in function and quality of life.

Providing Complex (Rather Than Complicated) Chronic Care

With health care reform underway, the results of the study by Sharma et al[1][1] emphasize the foundational role of primary care in our multimorbidity-based chronic care system. They found that the majority of patients with 14 high-cost chronic conditions saw general rather than specialist

APA Supports New Complex Chronic Care Management Codes

Back to table of contents Previous article Next article Government NewsFull AccessAPA Supports New Complex Chronic Care Management CodesMark MoranMark MoranSearch for more papers by this authorPublished Online:30 Oct 2013https://doi.org/10.1176/appi.pn.2013.11a17AbstractA proposed Medicare rule, issued in August, addresses regulatory and payment policy issues but does not include the fee schedule. A final rule with the fee schedule will be issued this month.APA is endorsing the government’s move toward incorporating “complex chronic care management codes” as part of the Medicare fee schedule for 2014.In response to a proposed rule issued by the Centers for Medicare and Medicaid Services (CMS) in August, then-APA Medical Director James H. Scully Jr., M.D., told CMS in a letter that the codes can create a means for compensating physicians for non-face-to-face services they provide to patients with complex chronic conditions.(The proposed rule by CMS was issued in August and addresses a variety of regulatory and payment policy issues, but does not include the 2014 fee schedule; a final rule, with the fee schedule, is expected this month. Look to Psychiatric News for coverage.)“APA strongly favors compensating physicians for the non-face-to-face care management, including, but not limited to, team conferences, telephone calls, and patient education they provide to Medicare beneficiaries suffering from chronic care conditions,” Scully wrote. “We commend CMS for moving in this direction, which we believe is a starting point. These codes cross an important barrier in not requiring face-to-face time. We support CMS’s proposal to utilize the parameters described in the CPT guidelines to identify patients eligible for complex chronic care condition management services. A disproportionate share of Medicare beneficiaries suffering from two or more chronic conditions are suffering from a mental illness as shown in CMS’s analysis of Medicare claims for patients with multiple chronic conditions.”But Scully also said that the conditions currently required for billing the newly proposed complex chronic care management service G codes are unlikely to capture the non-face-to-face care management work many psychiatrists are performing for some of Medicare’s most chronically ill beneficiaries.“Among the population of Medicare beneficiaries who comprise the severely and persistently mentally ill, our members often function additionally as primary care physicians, coordinating all or most of this population’s health care,” he wrote. “We urge Medicare to design complex chronic care management codes that our members can use when coordinating the health care of the chronically mentally ill Medicare population. This necessitates the design of complex chronic care management codes that have broader conditions of use, such as the two existing non-face-to-face CPT codes. We prefer the CPT codes because their use permits use of CPT guidelines and, consequently, other payers’ likely adoption of these codes.”Scully also expressed support for the adoption of the psychiatry CPT values, reviewed and approved earlier this year by the Relative Value Update Committee (RUC) for the 2014 Fee Schedule. “Adoption of the RUC recommended values is necessary to correct the current rank-order anomaly that exists between the psychiatric diagnostic evaluation with medical services (90792) and the psychiatric diagnostic evaluation (90791), which does not include medical services,” Scully wrote in a September 5 letter to CMS. “A disparity in payment was created by the adoption of RUC-recommended reductions in practice expense values for only 90792. The inequitable result of this is that psychiatrists and advance practice nurses have been paid less this year for doing more work with more complex patients. We believe this inequity created inappropriate incentives on the clinical level. This issue will be resolved if CMS adopts the RUC recommended practice expenses for the 90791.”Scully also urged the government to adopt new values for CPT codes for psychiatric services, as recommended by the RUC. Other issues Scully addressed included proposed rules around telehealth, liability for overpayment, quality measures, and the Medicare Physician Quality Reporting System. ■Scully’s letter to CMS is posted at http://www.psychiatry.org/advocacy--newsroom/advocacy/9e9023b8-d3da-4c85-a2a2-c02fa8cbad9a. ISSUES NewArchived

CPT 2014 Changes

New E/M codes for interprofessional consultations and hypothermia treatment of a critically ill neonate, additional instruction for reporting of existing E/M services, clarifications for critical care transport and trnsitional care managment, and revisions for complex chronic care coordination

Polypharmacy and bipolar disorder: what's personality got to do with it?

The majority of patients treated for bipolar disorder receive multiple psychotropic medications concurrently (polypharmacy), despite a lack of empirical evidence for any combination of three or more medications. Some patients benefit from the skillful management of a complex medication regimen, but iterative additions to a treatment regimen often do not lead to clinical improvement, are expensive, and can confound assessment of the underlying mood disorder. Given these potential problems of polypharmacy, this paper reviews the evidence supporting the use of multiple medications and seeks to identify patient personality traits that may put patients at a greater risk for ineffective complex chronic care. Patients with bipolar disorder (n = 89), ages 18 and older, were assessed on the Montgomery Asberg Depression Rating Scale (MADRS), Young Mania Rating Scale (YMRS), and the NEO Five Factor Inventory (NEO-FFI), and completed a treatment history questionnaire to report psychotropic medication use. We found that patients with lower scores on openness had significantly more current psychotropic medications than patients with higher scores on openness (3.7 ± 1.9 vs. 2.8 ± 1.8, p < 0.05). Patients with the highest lifetime medication use had significantly lower extraversion (21.8 ± 8.9 vs. 25.4 ± 7.6, p < 0.05) and lower conscientiousness (21.9 ± 8.2 vs. 27.9 ± 8.2, p < 0.01) than those reporting lower lifetime medication use. Low levels of openness, extraversion, and conscientiousness may be associated with increased psychotropic medication use. Investigating the role of individual differences, such as patient personality traits, in moderating effective polypharmacy warrants future research.

A Closer Look at Complex Chronic Care Coordination

Capturing and documenting the coordinated activities of the physician-led care team for complex chronic care.

Getting better at chronic care in remote communities: study protocol for a pragmatic cluster randomised controlled of community based management

BackgroundPrevalence and incidence of diabetes and other common comorbid conditions (hypertension, coronary heart disease, renal disease and chronic lung disease) are extremely high among Indigenous Australians. Recent measures to improve quality of preventive care in Indigenous community settings, while apparently successful at increasing screening and routine check-up rates, have shown only modest or little improvements in appropriate care such as the introduction of insulin and other scaled-up drug regimens in line with evidence-based guidelines, together with support for risk factor reduction. A new strategy is required to ensure high quality integrated family-centred care is available locally, with continuity and cultural safety, by community-based care coordinators with appropriate system supports.Methods/designThe trial design is open parallel cluster randomised controlled trial. The objective of this pragmatic trial is to test the effectiveness of a model of health service delivery that facilitates integrated community-based, intensive chronic condition management, compared with usual care, in rural and remote Indigenous primary health care services in north Queensland. Participants are Indigenous adults (aged 18–65 years) with poorly controlled diabetes (HbA1c>=8.5) and at least one other chronic condition. The intervention is to employ an Indigenous Health Worker to case manage the care of a maximum caseload of 30 participants. The Indigenous Health Workers receive intensive clinical training initially, and throughout the study, to ensure they are competent to coordinate care for people with chronic conditions. The Indigenous Health Workers, supported by the local primary health care (PHC) team and an Indigenous Clinical Support Team, will manage care, including coordinating access to multidisciplinary team care based on best practice standards. Allocation by cluster to the intervention and control groups is by simple randomisation after participant enrolment. Participants in the control group will receive usual care, and will be wait-listed to receive a revised model of the intervention informed by the data analysis. The primary outcome is reduction in HbA1c measured at 18 months. Implementation fidelity will be monitored and a qualitative investigation (methods to be determined) will aim to identify elements of the model which may influence health outcomes for Indigenous people with chronic conditions.DiscussionThis pragmatic trial will test a culturally-sound family-centred model of care with supported case management by IHWs to improve outcomes for people with complex chronic care needs. This trial is now in the intervention phase.Trial registrationAustralian New Zealand Clinical Trials Registry ACTR12610000812099

Implementation of complex adaptive chronic care: the Patient Journey Record system (PaJR)

The Patient Journey Record system (PaJR) is an application of a complex adaptive chronic care model in which early detection of adverse changes in patient biopsychosocial trajectories prompts tailored care, constitute the cornerstone of the model. To evaluate the PaJR system's impact on care and the experiences of older people with chronic illness, who were at risk of repeat admissions over 12 months. Community-based cohort study - random assignment into intervention and usual care group, with process and outcome evaluation. Adult and older patients with multiple morbidity, one or more chronic diseases with one or more overnight hospitalizations, and seven or more general practice visits in the past 6 months. COMPLEX INTERVENTION: PaJR lay care guides/advocates call patients and their caregivers. The care guides summarize their semi-structured conversations about health concerns and well-being. Predictive modelling and rules-based algorithms trigger alerts in relation to online call summaries. Alerts are acted upon according to agreed guidelines. Descriptive and comparative statistics. Impact on unplanned emergency ambulatory care sensitive admissions (ACSC) with an overnight stay; sensitivity of alerts and predictions; rates of care guides-supported activities. Five part-time lay care guides and a care manager monitored 153 intervention patients for 500 person months with 5050 phone calls. The 153 patients in the intervention group were comparable to the 61 controls. The intervention group reported in 50% of calls that their health limited their social activities; and one-third of calls reported immediate health concerns. Predictive analytics were highly sensitive to risk of hospitalization. ACSC admissions were reduced by 50% compared to controls across the sites. The initial implementation of a complex patient-centred adaptive chronic care model using lay care guides, supported by machine learning, appeared sensitive to risk of hospitalization and capable of stabilizing illness journeys in older patients with multi-morbidity. Actions based on alerts produced in this study appeared to significantly reduce hospitalizations. This paves the way for further testing of the model.

Using Research to Transform Care for Women Veterans: Advancing the Research Agenda and Enhancing Research–Clinical Partnerships

The purpose of this paper is to report on the outcomes of the 2010 VA Women's Health Services Research Conference, which brought together investigators interested in pursuing research on women veterans and women in the military with leaders in women's health care delivery and policy within and outside the VA, to significantly advance the state and future direction of VA women's health research and its potential impacts on practice and policy. Building on priorities assembled in the previous VA research agenda (2004) and the research conducted in the intervening six years, we used an array of approaches to foster research-clinical partnerships that integrated the state-of-the-science with the informational and strategic needs of senior policy and practice leaders. With demonstrated leadership commitment and support, broad field-based participation, strong interagency collaboration and a push to accelerate the move from observational to interventional and implementation research, the Conference provided a vital venue for establishing the foundation for a new research agenda. In this paper, we provide the historical evolution of the emergence of women veterans' health services research and an overview of the research in the intervening years since the first VA women's health research agenda. We then present the resulting VA Women's Health Research Agenda priorities and supporting activities designed to transform care for women veterans in six broad areas of study, including access to care and rural health; primary care and prevention; mental health; post deployment health; complex chronic conditions, aging and long-term care; and reproductive health.

Partnering Urban Academic Medical Centers And Rural Primary Care Clinicians To Provide Complex Chronic Disease Care

Many of the estimated thirty-two million Americans expected to gain coverage under the Affordable Care Act are likely to have high levels of unmet need because of various chronic illnesses and to live in areas that are already underserved. In New Mexico an innovative new model of health care education and delivery known as Project ECHO (Extension for Community Healthcare Outcomes) provides high-quality primary and specialty care to a comparable population. Using state-of-the-art telehealth technology and case-based learning, Project ECHO enables specialists at the University of New Mexico Health Sciences Center to partner with primary care clinicians in underserved areas to deliver complex specialty care to patients with hepatitis C, asthma, diabetes, HIV/AIDS, pediatric obesity, chronic pain, substance use disorders, rheumatoid arthritis, cardiovascular conditions, and mental illness. As of March 2011, 298 Project ECHO teams across New Mexico have collaborated on more than 10,000 specialty care consultations for hepatitis C and other chronic diseases.

Poster 182: Methylphenidate Effect on Time to Consciousness up to 1 Year. Theresa Pape (Center for Management of Complex Chronic Care, Center of Excellence) Edward Hines Jr., Vijaya Patil, Major Timothy Crane, Bridget Smith, Ann Guernon, Wei Vong, Charlene Tang, Melanie Querubin, Nenad Brkic

Poster 182: Methylphenidate Effect on Time to Consciousness up to 1 Year. Theresa Pape (Center for Management of Complex Chronic Care, Center of Excellence) Edward Hines Jr., Vijaya Patil, Major Timothy Crane, Bridget Smith, Ann Guernon, Wei Vong, Charlene Tang, Melanie Querubin, Nenad Brkic

Designing HIGH-COST medicine: hospital surveys, health planning, and the paradox of progressive reform.

Inspired by social medicine, some progressive US health reforms have paradoxically reinforced a business model of high-cost medical delivery that does not match social needs. In analyzing the financial status of their areas' hospitals, for example, city-wide hospital surveys of the 1910s through 1930s sought to direct capital investments and, in so doing, control competition and markets. The 2 national health planning programs that ran from the mid-1960s to the mid-1980s continued similar strategies of economic organization and management, as did the so-called market reforms that followed. Consequently, these reforms promoted large, extremely specialized, capital-intensive institutions and systems at the expense of less complex (and less costly) primary and chronic care. The current capital crisis may expose the lack of sustainability of such a model and open up new ideas and new ways to build health care designed to meet people's health needs.

Palliative care for HIV in the era of antiretroviral therapy availability: perspectives of nurses in Lesotho

BackgroundSouthern Africa is disproportionately affected by the HIV/AIDS epidemic. In Lesotho 23% of adults are HIV-positive, and only 26% of those in need are accessing antiretroviral treatment (ART). Consequently, about 18,000 people die from AIDS each year. In this situation, palliative care is needed towards the end of life, but is also recommended throughout the HIV disease trajectory. The World Health Organisation (WHO) has produced the Integrated Management of Adolescent and Adult Illness (IMAI) guidelines, which includes a palliative care guidebook (as well as acute and chronic ART guidebooks). IMAI aims to facilitate the implementation of integrated HIV/AIDS care in resource-poor areas. The opinions of health workers towards this integrated approach to care and the use of IMAI has not been considered in previous research studies. This paper therefore aims to address some of these issues.MethodsSemi-structured interviews were conducted with six key informants and ten nurses in Lesotho. The interviews were transcribed verbatim and analysed using content thematic analysis.ResultsMany nurses described palliative care as synonymous with chronic care and felt that palliative care is necessary for HIV-positive patients despite the introduction of ART. It was thought that the approach taken should be holistic and integrated throughout the disease trajectory. Pain management was noted to be a particular area of need for palliative care, and it was suggested that this could be improved in Lesotho. The IMAI guidelines were thought to be useful, but knowledge of the palliative care booklet was limited.ConclusionPalliative care remains necessary for HIV despite the increasing availability of ART. However, it is currently significantly lacking in Lesotho and many other sub-Saharan African countries. Greater understanding of palliative care amongst health workers is required, as well as strong political will from the Ministry of Health. The IMAI guidelines are a useful tool for holistic HIV care, including palliative care, but they need to be used more effectively. As ART is becoming increasingly available worldwide, the complex chronic care issues for patients with HIV/AIDS should not be neglected.

Coordinated care: what does that really mean?

The healthcare system in Australia is struggling to meet the healthcare needs of the ageing population. The pressure on health systems to solve these complex problems can create a sense of urgency to find a panacea in concepts such as coordinated care. A common understanding of coordinated care is often assumed when, in reality, the concept is neither clearly defined nor completely understood. The purpose of this review was to examine and identify the attributes of coordinated care to facilitate a shared definition of this concept within the primary care context. The study was a conceptual review of the literature relating to coordinated care in chronic disease. Two key electronic databases (MEDLINE and CINAHL) were searched using terms generated by a panel of primary healthcare practitioners and researchers. Following the application of inclusion and exclusion criteria, 20 studies were selected from an initial pool of 128. Several key attributes of coordinated care were identified together with a definitional statement. Coordinated care in the primary healthcare setting can be broadly defined as the delivery of systematic, responsive and supportive care to people with complex chronic care needs. It relies heavily on complicated concepts such as partnerships, networking, collaboration, knowledge transfer, person-centred practice and self-management support. The expression of these concepts in the literature was relatively superficial, with little discussion of the actual practices that might be implemented in order to enact them. This paper provides a framework of coordinated care within the primary care setting that can guide future work around implementation and evaluation.