health status and intensity of need for nursing care outcomes in a care coordination program with a...
TRANSCRIPT
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Health Status and Intensity of Need for Nursing Care Outcomes in a Care
Coordination Program with a Socially Vulnerable Population
Teresa Barry Hultquist, PhD, APRN-CNS;
Katherine Kaiser, PhD, APRN-CNS;
Jenenne Geske, PhD
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Project Support
This project is supported by funds from the Division of Nursing
(DN), Bureau of Health Professions (BHPr), Health
Resources and Services Administration (HRSA), Department
of Health and Human Services (DHHS) under D11HP08312,
Reducing Disparities in Type 2 Diabetes Through a Network
of Nursing Centers , $1.6 million. The information or content
and conclusions are those of the authors and should not be
construed as the official position or policy of, nor should any
official endorsement be inferred by, the DN, BHPr, HRSA,
DHHS, or the US Government.
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Objectives
♦ Describe the nurse-patient partnership care
coordination program implemented with
nursing students and clinic patients.
♦ Evaluate program results focused on
reducing disparities through increased
access to care and improving clinical
outcomes (e.g. intensity of need for care,
health status, depression and patient
empowerment) 3
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Objectives
♦ Apply lessons learned to current nursing
practice and care coordination efforts in
light of the Affordable Care Act.
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Vulnerable Patients with Chronic Conditions
♦ ACA focuses on quality care and outcomes
for all patients
♦ People manage their own health everyday:
diet, physical activity, sleep, medications
♦ Vulnerable patients with chronic conditions
need additional support to manage illness
effectively and minimize complications5
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Application to Vulnerable/Safety Net Populations
♦ Safety net/vulnerable populations
♦ May not have primary care provider
♦ ER Use for primary care
♦ Hospitalizations
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% of adults with diabetes greatest among those with least education & lowest household income (Nebraska DHHS, 2012; CDC, 2011)
Diabetes: Nebraska Adults (18 & older)
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Diabetes: Cost
8ADA, 2013; CDC, 2013; NE DHHS, 2012
♦ Cost of diabetes in US in 2012 was $245 billion, a 41% increase from 2007♦ $176 billion for direct medical costs♦ $69 billion in reduced productivity
♦ Medical costs are 2.3 times higher
♦ 7th leading cause of death in US & NE
♦ Death risk among people with diabetes is about twice that of people of similar age but without diabetes
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Chronic Care Model Components
♦ Clinical Information Systems
♦ Delivery System Redesign
♦ Decision Support
♦ Health Care Organization
♦ Community Resources
♦ Self-Management Support
Bodenheimer, Wagner, & Grumbach, 2002 9
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Self-Management
♦“the individual’s ability to mange the
symptoms, treatment, physical and social
consequences and lifestyle changes
inherent in living with a chronic condition”Barlow, Wright, Sheasby, Turner, Hainsworth, 2002, p.177
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Self-Management Support
♦“systematic provision of education and
supportive interventions to increase
patient’s skills and confidence in managing
their health problems, including regular
assessment of progress and problems,
goal setting, and problem-solving support”Adams & Corrigan, 2003, p.53
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Traditional Interactions
♦ Information is provided based on the
provider’s agenda.
♦ Belief that knowledge is sufficient to create
behavior change.
♦ Goal is compliance with the provider’s advice.
♦ Care decisions are made by the provider.
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Collaborative Student-Patient Interactions
♦ Information & skills training provided based
on patient’s agenda.
♦ Belief that self-efficacy (confidence in ability
to change) creates behavior change.
♦ Goal is increased self-efficacy, not
compliance with provider’s advice.
♦ Care decisions are made as a patient-
provider partnership. 13
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Nursing Student Home Visitation Intervention
Ambulatory Care Community Health Nursing Program
♦ Focus on assisting patients to better manage, interpret
and coordinate their chronic illness regimes
♦ Student as care provider, coordinator, educator,
advocate guided by faculty case managers
♦ Assess patient need for nursing care and change in
status over time (CHIRS, HSQ-12, PHQ-9, DES)
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Intensity of Need for Care
Public and Community Health Nursing Context:
♦ More than health problems
♦ Not acuity based on seriousness
♦ Patient subjective and nurse evaluation of health need
♦ Nursing resources consumption including frequency of
contact
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Client Intensity of Need Instrument
Community Health Intensity Rating Scale (CHIRS)
♦ 15 parameters (representing 4 conceptual domains:
environmental, psychosocial, physiological, health
behaviors); ratings from 0-4; 2-4 moderate to high
parameter score
♦ Intensity of Need score 0-60 (sum of the 15 parameter
scores); 60 highest intensity; >30 moderate to high
intensity
16Hays, Sather & Peters, 1999; Kaiser, 2012
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Self-Reported Health Status Instrument
Health Status Questionnaire-12 (HSQ-12)
♦ Designed to capture the judgment of an individual
regarding his/her well-being and level of functioning that
can change over time
♦ 12 items about physical and mental health
♦ THS (Total Health Status) scoring from 0-800, with
higher levels indicating better perceived health status
♦ PHSS & MHSS (Physical and Mental Health Status
Scores) scoring from 0-40017Barry, Kaiser, & Atwood, 2007; Radosevich & Pruitt,
1996
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Depression Instrument
Patient Health Questionnaire (PHQ-9)
♦ Self-report screening tool to indicate depressive
symptoms and severity of symptoms
♦ 9 items scored: Not At All (0) to Nearly Every Day (3)
♦ Scoring from 0-27:
1-4 Minimal 15-19 Moderately Severe
5-9 Mild 20-27 Severe
10-14 Moderate
Spitzer, Williams, Kroenke et al, 1999; Löwe, Unützer, Callahan, Perkins, Kroenke, 2004; Martin, Rief, Klaiberg, Braehler, 2006 18
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Psychosocial Self-Efficacy
Diabetes Empowerment Scale–Short Form (DES-SF)
♦ Measures patient self-efficacy r/t psychosocial issues of
managing diabetes
♦ 8 items about need for change, developing a plan,
overcoming barriers, asking for support, etc.
♦ Scoring averages sum of 8 items from 1-5, with higher
scores indicating better perceived self-efficacy for diabetes
management
Anderson, Funnell, Fitzgerald, Marrero, 2000; Anderson, Fitzgerald, Gurppen, Funnell, & Oh, 2003 19
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Action Plan
Getting Active♦ I will start walking for 10 minutes a day, three times weeklyMy Diet♦ I will switch to diet pop
Confidence Level♦ 7 or above
Goal Met♦ All of the time♦ More than 50% of the time♦ Less than 50% of the time♦ None of the time
20Adapted from Anderson & Christison-Lagay, 2008; Lorig et al., 2006
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Study Purpose
Reduce disparities through increased access to
care and improve clinical outcomes (e.g.
intensity of need for care, health status,
depression and patient empowerment)
Summer 2008-Fall 2011
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Sample
♦ 28 adults with diabetes receiving health care from a
nurse managed primary care clinic
♦ Gender:
♦ Males (n=10) ♦ Females (n=18)
♦ Marital Status:
♦ Married (n=13) ♦ Not Married (n=15)
♦ Age:
♦ Average=57 (SD=11.1) ♦ Range 34-8322
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Sample
♦ Income:
♦ <$10,000 (n=14)
♦ $10,000 - $30,000 (n=13)
♦ $30,000 - $50,000 (n=1)
♦ Number in Household:
♦ Average 3.3 (SD=2.8) ♦ Range 1-11
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Sample
♦ Primary Language:
♦ English (n=16) ♦ Spanish (n=12)
♦ Race:
♦ White (n=16) ♦ Native American
(n=1)
♦ Other/Missing (n=11)
♦ Ethnicity:
♦ Hispanic (n=12) ♦ Not Hispanic (n=16)24
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Sample
♦ Insurance:
♦ Uninsured (n=19) ♦ Medicare (n=6)
♦ Medicaid (n=2) ♦ Other (n=1)
♦ Pharmacy:
♦ HOPE (n=11) ♦ Commercial
(n=13)
♦ Missing (n=4)
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CHIRS Results
Average CHIRS Total Scores
Time 1 Time 2 Time 3 Time 4
Mean 31.4 32.9 30.5 31.5
SD 6.5 6.3 6.8 7.7
Range 17-47 19-47 19-39 19-42
n 28 28 14 14
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Highest Parameter Mean Scores: Time 1 & 2: Admission & Discharge (n=28)
♦ P 8 (Respiratory/Circulatory) 3.00/3.00
♦ P 13 (Nutrition) 2.75/2.86
♦ P 5 (Emotional/Mental Response) 2.64/2.61
♦ P 12 (Structural Integrity)
2.57/3.00
♦ P 7 (Sensory Function) 2.54/2.57
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Lowest Parameter Mean Scores: Time 1 & 2 Admission & Discharge (n=28)
♦ P 10 (Reproduction) 0.86/0.89
♦ P 3 (Community Networking) 1.25/1.39
♦ P 14 (Personal Habits) 1.32/1.32
♦ P 9 (Neuromuskuloskeletal Function) 1.36/1.46
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HSQ-12 Results – Entire Sample
Time 1 (n=28) Time 2 (n=15)
HSQ-12 Total Score
Mean 483.6 469.8
SD 173.8 165.4
Range 120-745 192-754
HSQ-12 Physical Score
Mean 223.6 207.4
SD 93.6 97.6
Range 35-400 35-385
HSQ-12 Mental Score
Mean 260.0 262.4
SD 95.2 84.5
Range 85-400 117-380
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HSQ-12 Results – Time 1 vs. Time 2Time 1 (n=15)
Time 2 (n=15) p-value*
HSQ-12 Total Score
Adjusted Mean* 462.0 469.8 0.32
SD 195.0 165.4
HSQ-12 Physical Score
Adjusted Mean 212.8 207.4 0.36
SD 103.1 97.6
HSQ-12 Mental Score
Adjusted Mean 249.2 262.4 0.93
SD 103.9 84.5
* Based on analysis of covariance (ANCOVA) controlling for the number of days between time 1 and time 2 (average number of days = 156)
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PHQ-9 ResultsTime 1 Time 2
Level of Depression # % # %
None 9 33.3 4 26.7
Mild 7 25.9 6 40.0
Moderate 4 14.8 5 33.3
Moderately Severe 5 18.5 0 0
Severe 2 7.4 0 0
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PHQ-9 Results – Entire SampleTime 1
n=27Time 2
n=15
Mean 8.5 7.6
SD 6.9 4.6
Range 0-23 0-16
Time 1n=14
Time 2n=14 p-value*
Adjusted Mean* 9.5 7.0 0.06
SD 6.7 4.1
PHQ-9– Time 1 vs. Time 2
* Based on analysis of covariance (ANCOVA) controlling for the number of days between time 1 and time 2 (average number of days = 328)
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DES Results – Entire SampleTime 1
n=28Time 2
n=15
Mean 4.3 4.4
SD .6 .6
Range 2.9-5.0 3.4-5.0
Time 1n=14
Time 2n=14 p-value*
Adjusted Mean* 4.4 4.4 0.14
SD .5 .6
DES Results – Time 1 vs. Time 2
* Based on analysis of covariance (ANCOVA) controlling for the number of days between time 1 and time 2 (average number of days = 153)
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Action Plan Results
Indicated this Activity
as a Goal Confidence
Goals Met
None of the time
# %
Less than 50% of the
time# %
More than 50% of the
time# %
All of the time
# % # % Mean SDExercise 63 43% 8.57 1.67 1 3.6% 7 25.0% 14 50.0% 6 21.4%Diet 41 28% 7.31 1.79 0 5 31.3% 9 56.3% 2 12.5%Blood Sugar 24 17% 7.75 2.37 0 3 33.3% 2 22.2% 4 44.4%Feelings 6 4% 9.00 2.83 1 33.3% 1 33.3% 1 33.3%
Foot Checks 5 3% 8.00 2.45 1100.0
%Meds 4 3% 7.67 2.52 1 33.3% 1 33.3% 1 33.3%Smoking 2 1% 9.00 1.41 1 50.0% 1 50.0%
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Initial A1C Levels
35
♦ Those with A1Cs drawn within 2 months of
the initial student visit (n=20)
Average = 8.6 (SD=3.2)
Range = 5.8-13.4
< 7.0 = 7 patients
7.1-8.9 = 9 patients
> 9.0 = 4 patients
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CHIRS by HSQ-12, PHQ-9, DES at T11. The CHIRS Total score is negatively correlated with the HSQ-12 Total
score (r=-.408, p=0.03) and with the HSQ-12 Physical score (r=-.433,
p=0.02) As the CHIRS total score ↑’s (more need) the HSQ-12 scores ↓
(lower perceived health status)
2. The CHIRS Parameter 5 score (Emotional / Mental Response) is
negatively correlated with the HSQ-12 Total score (r=-.411, p=0.03) and
HSQ-12 Mental score (r=-.514, p=0.005) As the CHIRS parameter score
↑’s (more need) the HSQ-12 scores ↓ (lower perceived health status)
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CHIRS by HSQ-12, PHQ-9, DES
37
3. The CHIRS Parameter 6 score (Individual Growth and Development) is
negatively correlated with the HSQ-12 Total score (r=-.401, p=.04) and with
the HSQ-12 Mental score (r=-.387, p=.04). As the CHIRS parameter score
↑’s (more need) the HSQ-12 scores ↓ (lower perceived health status)
The CHIRS Parameter 6 score is positively correlated with the PHQ-9
(r=.392, p=.04). As the CHIRS parameter score ↑’s (more need) the PHQ-9
scores ↑ (higher perceived depression)
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Lessons Learned and Practice Implications
♦ Clinical improvement takes more time and
more resources (greater nursing dose) for
the medically and socially vulnerable.
♦ Nurse to nurse coordination models are
needed between inpatient (including ER)
and outpatient primary care/medical
homes.
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Lessons Learned and Practice Implications
♦ Students can provide valuable support and
resources (time) for HC providers and patients
if they are valued as team members.
♦ Self-reported health status is a reliable and valid
measure r/t morbidity and mortality. It is logical
that in a comprehensive measure like the
CHIRS, nurses would factor in client
perceptions in their assessments.39
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Lessons Learned and Practice Implications
♦ Intensity of need for care, PHQ-9, & SRHS
results illustrate that psychosocial needs are
important to pay attention to beyond just
physical findings. This demonstrates that in
case management, we need to move towards
more evidence based psychosocial
interventions.
40
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Vulnerable/Safety Net Populations
♦ Outreach is important, it is expensive but to
reduce overall HC costs, need to go to
patients especially in the beginning
♦ No good way to assess vulnerability – has
many dimensions, not just income
♦ Health promotion & clinical prevention needs
to be addressed even with other priorities
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action: transforming health care quality. Washington, D.C.: National Academy Press.
Anderson, D & Christison-Lagay, J. (2008). Diabetes self-management in a community health
center: improving health behaviors and clinical outcomes for underserved
patients. Clinical Diabetes, 26(1), 22-27.
Anderson, R., Fitzgerald, J., Gurppen, L., Funnell, M., & Oh, M. (2003). The diabetes
empowerment scale-short form (DES-SF). Diabetes Care, 26, 1641-1642.
Anderson, R., Funnell, M., Fitzgerald, J., & Marrero, D. (2000). The diabetes empowerment
scale: a measure of psychosocial self-efficacy. Diabetes Care, 23, 739-743.
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