Transcript Slide 1

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
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)
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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 complications
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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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Diabetes: Nebraska Adults (18 & older)
% of adults with diabetes greatest among those with least education & lowest household
income (Nebraska DHHS, 2012; CDC, 2011)
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Diabetes: Cost
♦ 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
ADA, 2013; CDC, 2013; NE DHHS, 2012
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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
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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 patientprovider partnership.
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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
Hays, 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 0-400
Barry, 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
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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
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Action Plan
Getting Active
♦ I will start walking for 10
minutes a day, three times
weekly
My 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
Adapted 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 34-83
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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)
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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
17-47
19-47
19-39
19-42
28
28
14
14
Range
n
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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
Mean
260.0
262.4
SD
95.2
84.5
Range
85-400
117-380
HSQ-12 Mental Score
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HSQ-12 Results – Time 1 vs. Time 2
Time 1
(n=15)
Time 2
(n=15)
p-value*
Adjusted Mean*
462.0
469.8
0.32
SD
195.0
165.4
Adjusted Mean
212.8
207.4
SD
103.1
97.6
Adjusted Mean
249.2
262.4
SD
103.9
84.5
HSQ-12 Total Score
HSQ-12 Physical Score
0.36
HSQ-12 Mental Score
0.93
* 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 Results
Time 1
Level of Depression
Time 2
#
%
#
%
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 Sample
Time 1
n=27
Time 2
n=15
Mean
8.5
7.6
SD
6.9
4.6
Range
0-23
0-16
PHQ-9– Time 1 vs. Time 2
Time 1 Time 2
n=14
n=14
Adjusted Mean*
9.5
7.0
SD
6.7
4.1
p-value*
0.06
* 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 Sample
Time 1
n=28
Time 2
n=15
Mean
4.3
4.4
SD
.6
.6
Range
2.9-5.0
3.4-5.0
DES Results – Time 1 vs. Time 2
Time 1 Time 2
n=14
n=14
Adjusted Mean*
4.4
4.4
SD
.5
.6
p-value*
0.14
* 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
Goals Met
None of the
time
SD
#
%
Confidence
#
%
Mean
Exercise
63
43%
8.57
1.67
1
Diet
41
28%
7.31
1.79
Blood Sugar
24
17%
7.75
Feelings
6
4%
Foot Checks
5
Meds
Smoking
3.6%
Less than
50% of the
time
#
%
More than
50% of the
time
#
%
All of the
time
#
%
7
25.0%
14
50.0%
6
21.4%
0
5
31.3%
9
56.3%
2
12.5%
2.37
0
3
33.3%
2
22.2%
4
44.4%
9.00
2.83
1
1
33.3%
1
33.3%
3%
8.00
2.45
1
100.0
%
4
3%
7.67
2.52
1
33.3%
1
33.3%
2
1%
9.00
1.41
1
50.0%
1
50.0%
33.3%
1
33.3%
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Initial A1C Levels
♦ 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 T1
1. 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
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.
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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.
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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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References
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