Nurse Case Management Program Research Articles

The Effects of Nursing Case Management on Self-Care Behaviors, Clinical Outcomes, and Quality of Life Among Community-Dwelling Older Adults with Poorly Controlled Type 2 Diabetes in Thailand

ABSTRACT This study evaluated the effectiveness of nursing case management on self-care, clinical outcomes, and quality of life in community-dwelling older adults with poorly controlled type 2 diabetes in Thailand. The research employed a quasi-experimental, single-group, pretest – posttest design. Methods: Twenty-three participants participated in a 12-week nursing case management program, which was tailored to the individual’s needs and abilities, as well as their family, community, and healthcare context. Self-care behaviors increased significantly (p = .000) after implementation of the case management program, while waist circumference, fasting capillary blood glucose, and hemoglobin A1c decreased significantly (p = .001, p = .000, p = .003, respectively) from pre-intervention values. Quality of life was significantly better after the program (p = .000) than before. Results suggest that implementing tailored nursing case management could increase self-care behaviors and quality of life while decreasing waist circumference, fasting capillary blood glucose, and hemoglobin A1c in community-dwelling older adults with poorly controlled type 2 diabetes. The effectiveness of nursing case management depends on the healthcare context, the training and expertise of case managers, as well as the patient’s needs and preferences. Furthermore, the availability of families and communities can influence the nursing case management outcomes.

Care Coordination: A Principle of 21st Century School Nursing Practice With a Focus on Case Management.

The Framework for 21st Century School Nursing Practice™, created by the National Association of School Nurses (NASN), explains school nursing practice, providing guidance, organization, prioritization, and meaning. This is the second article in a series for The Framework for 21st Century School Nursing Practice. This article focuses on case management, one of the practice components in the principle of care coordination. Case management focuses on school nurse support of individual at-risk students and collaborative actions to reduce barriers to their academic success. This article will clarify how the terms care coordination and case management are used in context of the Framework and provide an example to help the reader apply the concept to practice. Washington's School Nurse Case Management Program will serve as a model. The program outlines evidence for effective practice and shares practical examples of how school nurses can implement case management into their daily work. Any school nurse, no matter how large or small their workload, can provide case management.

Nursing Case Management Strategies for Adults with Serious Mental Illness Seeking Dental Services

ABSTRACTA university-community partnership initiated a dental screening and nursing case management program for Medicaid-insured adults with serious mental illness (SMI). Forty-three adults with SMI participated in dental screening; 72% participated in case management. Per client, an average of six case management contacts was made. After 6 months, 87% (27/31) had attended at least one dental appointment, with a 13% no-show rate; 8 completed treatment, 4 had ongoing treatment, 12 had interrupted care, and 3 were lost to follow-up. Adults with SMI experienced high unmet dental needs; nursing case management strategies aided clients to initiate and complete dental care.

Developing a Rural Transitional Care Community Case Management Program Using Clinical Nurse Specialists

This quality improvement project developed a community nursing case management program to decrease preventable readmissions to the hospital and emergency department by providing telephonic case management and, if needed, onsite assessment and treatment by a clinical nurse specialist (CNS) with prescriptive authority. As more people reach Medicare age, the number of individuals with worsening chronic diseases with dramatically increases unless appropriate disease management programs are developed. Care transitions can result in breakdown in continuity of care, resulting in increased preventable readmissions, particularly for indigent patients. The CNS is uniquely educated to managing care transitions and coordination of community resources to prevent readmissions. After a thorough SWOT (strengths, weaknesses, opportunities, and threats) analysis, we developed and implemented a cost-avoidance model to prevent readmissions in our uninsured and underinsured patients. The project CNS used a wide array of interventions to decrease readmissions. In the last 2 years, there have been a total of 22 less than 30-day readmissions to the emergency department or hospital in 13 patients, a significant decrease from readmissions in these patients prior to the program. Three of them required transfer to a larger hospital for a higher level of care. Using advanced practice nurses in transitional care can prevent readmissions, resulting in cost avoidance. The coordination of community resources during transition from hospital to home is a job best suited to CNSs, because they are educated to work within organizations/systems. The money we saved with this project more than justified the cost of hiring a CNS to lead it. More research is needed into this technology. Guidelines for this intervention need to be developed. Replicating our cost-avoidance transitional care model can help other facilities limit that loss.

Implementation of a diabetes nurse case management program in a primary care clinic: a process evaluation

wolber t & ward d (2010) Journal of Nursing and Healthcare of Chronic Illness 2, 122–134 Implementation of a diabetes nurse case management program in a primary care clinic: a process evaluationAims and objectives. The aim was to evaluate the design and implementation of a diabetes nurse case management program in a busy primary care practice. The process outcomes include: (1) demonstration of nurse competence in motivational interviewing techniques, collaborative use of medication protocols, and identification of achievable self‐management goals; (2) achieving a caseload of 15 to 20 patients; (3) evidence of weekly patient contacts; (4) demonstration of collaboration with primary care providers; (5) sustainability of the program through staff changes.Background. Program success or failure is determined not only by sound assumptions regarding how the interventions work but also by the strategy of implementation used and whether it was implemented properly. The utilisation of nurse case managers skilled in motivational interviewing techniques, independent use of medication protocols, and application of patient self‐management goals have improved patient diabetic outcomes in multiple settings. There is little literature on how to translate this evidence into busy primary care settings.Method. Four generalist nurses, trained in motivational interviewing, medication protocols and diabetes self‐management contacted patients by phone at one to two week intervals over a six‐month period. Quantitative evaluation was done through chart review and taped nurse encounters. Qualitative information was obtained using structured nurse interviews and participant observations at monthly nurse/provider meetings.Conclusions. Key attributes necessary for successful implementation include embracing principles of redesign at all levels, access to a central data base and electronic medical records for time efficiency, constant redistribution of tasks among team members, continuous constructive feedback to reach nurse competency, and a frank discussion of nursing scope of practice and autonomy.Relevance to clinical practice. This study identifies a promising model to implement nurse case management in primary care. Early outcome results favour dissemination across the organization. Adaptation of this program to other settings is possible using process evaluation planning.

Nurse Case Management Program of Chronic Pain Patients Treated with Methadone

Methadone treatment in chronic pain patients is still limited owing to misconceptions about addiction, safety, and its unique pharmacokinetic and pharmacodynamic properties. Nevertheless, patients with chronic noncancer pain are frequently treated with methadone at our Pain Centre either as the first opioid of choice, for specific pain conditions, or as a second-line opioid in patients developing tolerance or intractable side effects with other opioids. The aim of this study was to examine whether a nurse case management program of chronic pain patients treated with methadone is feasible and safe in trying to improve patients’ care in an ambulatory setting. This program consisted of three phases: initial primary education session, telephone follow-up during methadone titration, and a subsequent maintenance period. The nurse case manager functioned autonomously and when required reported to and consulted the physician. The study included 75 subjects and was done over a nine-month period by completing follow-up questionnaires for every call. Of a total of 194 recorded calls, 41% were unscheduled. Forty-four percent of phone calls resulted in a methadone increase and 11% led to a decrease or cessation of methadone. No patients developed serious morbidity or mortality. Fifty-seven percent of patients were either satisfied or very satisfied with their treatment. A nurse-led case management program of methadone in chronic pain patients can improve patient care in an ambulatory setting.

A Nursing Case Management Program for Low-Income High-Risk Diabetic Clients

Case management has been widely promoted as a method that can improve clinical outcomes and reduce healthcare costs. This article describes a cost-benefit analysis for a proposed nursing case management program that provides care for a low-income high-risk diabetic population in a rural county. Industry trends, objectives and functions of the case management program, timeline, financial plan, and cost analysis are described. The analysis indicated a potential net savings of 149,544 dollars annually. This would be a significant cost savings for the healthcare provider and funding source.

A Nursing Case Management Program for Low-Income High-Risk Diabetic Clients

A Nursing Case Management Program for Low-Income High-Risk Diabetic Clients

Diabetes nurse case management: An effective tool

In March 2000, a large tertiary military medical treatment facility on the east coast implemented a diabetes nurse case management program to coordinate care for patients with diabetes mellitus type 1 or type 2 and a hemoglobin A1c value of 8.0% or greater. Although proven successful for patients while enrolled in the program, there was a lack of research that evaluated how successful patients were at continuing diabetes self-management once discharged. This study evaluated glycosylated hemoglobin A1c (A1c), total cholesterol (TC), triglyceride, and low-density lipoprotein (LDL) levels in patients at admission, discharge, and 6 months following discharge from the program. A retrospective medical record review of laboratory data was evaluated using descriptive statistics and paired t-test. Significant reductions in A1c and TC values from admission to discharge were achieved, which the patients maintained 6 months following discharge. There was also a significant reduction in LDL value from admission to 6 months following discharge. This study supports the value of nurse case management for patients with diabetes.

Outcomes of Project Dulce: A Culturally Specific Diabetes Management Program

Diabetes mellitus is a common and costly chronic disease that increasingly affects minority populations; however, there is little evidence regarding the clinical effectiveness and costs of culturally appropriate disease management programs. To determine the clinical outcomes and costs of Project Dulce, a combined stepped-care diabetes nurse case management program and culturally oriented peer-led self-empowerment training program. Pre-post clinical outcome and cost analysis of Project Dulce participants were compared with a cohort of historical controls over a one-year period. Subjects included 348 persons with diabetes with coverage under County Medical Services who were receiving services in community health centers in San Diego, CA. Generalized regression models were used to estimate changes in clinical outcomes (hemoglobin [Hb] A1c, blood pressure, cholesterol level) and costs associated with participation in Project Dulce. Project Dulce participants had significant reductions in HbA1c (0.8%; p < 0.001), systolic (5.4 mm Hg; p = 0.001) and diastolic (8.0 mm Hg; p < 0.001) blood pressure, total cholesterol (28.1 mg/dL; p < 0.001), and low-density-lipoprotein cholesterol (15.6 mg/dL; p < 0.001). Expenditures for pharmacy ($3157 Dulce vs $1618 control) and disease management ($507 Dulce) increased. Total costs were higher during the first year of disease management ($5711 Dulce vs $4365 control; p < 0.001). Project Dulce was effective in improving clinical outcomes for control of diabetes and related conditions in a medically indigent, culturally diverse population. Our finding of reduced hospital expenditures, although statistically insignificant, is clinically and economically important and suggests that intervention might provide an immediate benefit to a high-risk population.

Program, Practice, and Vision: Standardized Nursing Language and the Computerized Patient Record

BACKGROUNDIn 1997, the community‐based Nurse Case Management program of Aurora Health Care in Milwaukee, WI, was created to coordinate care for highrisk clients. Advanced practice nurse case managers partner with clients, families, and providers to establish goals and support efficient and effective use of healthcare resources. Clients referred to the program have evidence of suboptimal self‐management, complex health conditions, multiple specialty providers, or a history of high or inappropriate service utilization. Clients are typically seen in their homes, medical clinics, outpatient or other community sites.MAIN CONTENT POINTSFrom the start, the program was designed to provide coordinated care across the entire care continuum. Access to patient encounters, clinical, and financial data was identified as an essential component to providing and evaluating individual and program outcomes. The staff also needed a way to input data into the system. The program director was able to justify educational and information system support for the creation of a program‐specific documentation program. She valued the use of standardized nursing language as a way to capture and retrieve data about the discipline‐specific aspects of care. The NANDA, NIC, and NOC taxonomies were selected as the cornerstone for the nursing department of the largest Aurora hospital and the nurse case manager program. Administration further provided support for the department to partner with the established information system vendor in the creation of new software specifically designed to function within the integrated healthcare delivery system.The program was established based on the American Nurses Association standards for advanced practice and literature‐based best practice guidelines for patient care. Prior to implementation, the staff had basic computer access and limited standardized nursing language experience with NANDA diagnoses. The group set out to learn more about the NANDA/NIC/NOC taxonomies by attending a conference, using self‐study techniques from texts, and applying the concepts in their clinical practice. Several common patient problems and nursing interventions were recognized immediately. Sample plans with suggested NANDA/NIC/NOC linkages were developed for staff to use as a framework to tailor to the unique needs of their patients. Networking with colleagues provided an avenue to build confidence and consensus regarding taxonomy application.The documentation system was designed on paper and evolved into the program‐specific component of the systemwide computerized patient record. In addition to education, the staff invested much time in designing and developing expertise in computer use. Care Manager, the program‐specific software, went live in January 2000 and provided the case managers with a vehicle to access data, enter clinical notes and care plans, share data between providers, and track patient outcomes over time.CONCLUSIONSIt is important for users to have a clear vision of the functionality needed for practice. Significant educational and information system resources are needed. “Superusers” and focused education can increase the speed and efficiency of design and implementation processes.Because standardized nursing language is used to describe practice, staff members must develop expertise in using this terminology language to describe assessments, diagnoses, outcomes, and interventions in their daily practice. The next steps involve increasing system functionality to allow for more efficient documentation of assessments and interventions on the care plan and improve the ability to prescribe specific interventions within a NIC label. In regard to research, standardized nursing language provides a framework for descriptive and correlational studies that identify those interventions most effective in achieving best practice outcomes. Case managers need to use change theory to identify stage of readiness, appropriate NOCs to describe incremental change, and most effective NICs to promote patient movement toward action.

Evidence-based care for depression in Maine: dissemination of the Kaiser Permanente Nurse Telecare Program.

This paper describes the program model, implementation and preliminary results from a dissemination of a nurse case management program for treating depression in primary care. The program design was modeled after the Kaiser Permanente Nurse TeleCare program, which in a randomized clinical trial had previously demonstrated significant improvement in depression outcomes and patient satisfaction over usual care. As illustrated in this pilot by patient outcomes measured using the Hamilton Depression Rating Scale, the SF-12 Mental Health Composite Score, and the Work Role, Household and Leisure Time Functioning, the authors believe that it is possible to implement successful interventions in smaller primary care practices in community-based settings.

Nurse case management of hypercholesterolemia in patients with coronary heart disease: Results of a randomized clinical trial

Background Despite the large body of evidence confirming the effectiveness of lipid lowering for the secondary prevention of coronary heart disease (CHD) events, undertreatment of hyperlipidemia is common. This study tested the effectiveness of a nurse case management program to lower blood lipids in patients with CHD. Methods A total of 228 consecutive, eligible adults with hypercholesterolemia and CHD were recruited during hospitalization after coronary revascularization. Patients were randomized to receive lipid management, including individualized lifestyle modification and pharmacologic intervention, from a nurse practitioner for 1 year after discharge in addition to their usual care (NURS), or to usual care enhanced with feedback on lipids to their primary provider and/or cardiologist (EUC). Results Significantly more patients in the NURS group than in the EUC group achieved low-density lipoprotein cholesterol (LDL-C) levels <2.59 mmol/dL (100 mg/dL, 65% vs 35%, P =.0001). Favorable changes in lipids and lipoproteins were accompanied by significant improvements in dietary and exercise patterns in the NURS group. In a multivariate analysis adjusting for other covariates, being assigned to the NURS group (P =.0001) and being on a lipid-lowering medication (P =.001) were significant independent predictors of LDL-C level. Conclusions Control of hypercholesterolemia in patients who have undergone coronary revascularization can be improved by a nurse case-management program. Because the National Cholesterol Education Program Adult Treatment Panel III guidelines have broadened the definition of high-risk populations that warrant aggressive treatment, nurse case-management programs may offer key opportunities to enhance appropriate application of new treatment paradigms. (Am Heart J 2002;144:678-86.)

Injured Workers' Perceptions of Case Management Services

This article describes the findings from a study of injured workers conducted as part of a multifaceted evaluation study of a case management program. The sample consisted of workers who filed a workers' compensation claim between January 1 and September 30, 1995. Data collection consisted of written surveys (n = 45), personal interviews (n = 27), and telephone interviews (n = 16). The findings from this study provided many insights into the injured workers' personal and work experiences, and, in particular, their perceptions of their experience with the nurse case management program. Workers satisfied with services described the nurse case manager (NCM) as having the ability to see the "big picture," to develop appropriate goals, and to anticipate client needs. Dissatisfied workers reported feeling unimportant in terms of service provision. They reported feeling that "the system" did not respond to their needs, and that the NCM was uninterested and disrespectful. This vivid portrayal of workers' experiences and perceptions of case management services provides valuable information about the world view of the injured worker.

Case Management in an Integrated Delivery System

A case management program is designed so that the nurses could work with any client within the health system, regardless of the diagnosis of provider. A variety of challenges surfaced: maintaining visibility within a large health care system; working with varied approaches to client care issues; and being clinically knowledgeable in the variety of chronic illnesses. Hospital admissions, physician and emergency department visits and costs are measured after establishing a nurse case management program.

Development and implementation of an agency management and evaluation of care program

Community and home health nurses have recognized case management as a core component of home care since the inception of home health agencies. As the interpretation of the reimbursement for coordination activities has broadened, agencies have been able to derive some payment for these services. This article describes the development of a nursing case management program that focuses on the nursing practice model. It discusses goals and criteria developed and the risk factors identified, along with the management and evaluation activities that are key to this case manage ment model.

Hospital Case Management: Bridging Acute And Long-Term Care

Since the early 1980s, policymakers and analysts have urged hospitals to be more active in managing the care of their patients beyond the hospital walls. In particular, hospitals have been criticized for failing to address the postdischarge needs of elderly patients with chronic health problems. An influential essay in The New England Journal of Medicine observed that “most of these institutions have no comprehensive geriatric program geared to the long-term medical, rehabilitative, and social needs that are linked to acute illness. To provide quality care, hospitals must make a commitment to long-term care for the chronically ill elderly patient. It is becoming apparent that no one else can.” As part of a strategy for addressing this perceived shortcoming, the authors argued, “Unlike other providers, hospitals could offer comprehensive case management of patients, from home care to acute care, thus ensuring continuity of services.” Under this approach, hospital-based case managers would identify clients, assess their needs, develop care plans, coordinate service delivery, and monitor results. Since many of these activities would take place after the patient left the hospital, hospital-based case management would be a considerable extension of hospitals’ typical discharge planning activities. In part, it was expected that the costs of hospital-based case management programs would be covered through user fees. If the hospital also offered long-term care services, hospital-based case management could generate additional revenues through increased use of these services. If it facilitated the earlier discharge of Medicare patients and reduced Medi-

Care and Cost

In 1988, about $960,000 of billed charges and 430 patient days were saved through the nursing case management program.