Transcript Meeting the Patient Where They are Does Not Mean Halfway: The

 Nancy L. Rothman, MSN, EdD, RN
Independence Foundation Professor of Urban Community Nursing
Dept . Of Nursing, CHP&SW, Temple University
 Cheryl Peterson, MSN, RN
Director Department of Nursing Practice and Policy
American Nurses Association
 Paula DeCola, MSC, RN
Senior Director, External Medical Affairs
Pfizer, Inc.
 Nancy De Leon Link, MGA
Chief Operating Officer
National Nursing Centers Consortium
Presenter Disclosures
 The following personal financial relationships with
commercial interests relevant to this presentation
existed during the past 12 months:
No relationships to disclose
Initiative Description
 Evaluating nurse-led primary
care in NCQA recognized
Patient-Centered Medical
Homes with CRNP and RN Care
Manager teams
 In two primary care clinics in
public housing
 African American women 18-60
years of age diagnosed with
diabetes, hypertension,
hyperlipidemina or at risk due to
a BMI > 30; n-116
Public Health Management
Corporation Nursing Network
PHMC Health Connection
Rising Sun Health Center
Intervention Development
 IRB approval first for initial
focus groups and then for
intervention study and post
intervention focus groups
 Focus groups (8-10 patients) at
two NCQA recognized nurse-led
primary care clinics conducted
to investigate how to improve
health outcomes of African
American Women who are
diagnosed or at risk for
cardiovascular disease
 Intervention designed based
upon initial focus groups –
individual coaching by RN Care
Managers
 Analyzed process and outcome
measures
 Focus groups (8-10) at same two
NCQA recognized nurse-led
primary care clinics to measure
satisfaction with the
intervention
Pre-intervention
patient focus groups:
 Expressed confusion and concern about medication use, diet and self
management of diabetes.
 “I am on two medications for my blood pressure and three for my diabetes.
It is back and forth, back and forth trying to get the results they want.”
 “You have to stay stable; you have to eat breakfast on time and you have to
eat between meals.”
 Stressed difficulty adopting a diet that would allow them to lose weight
or maintain a better blood sugar level.
 “Sometimes I get nervous, like when I don’t eat…I realize my sugar is low…it
can go under 70 , that’s when I feel it.”
 Indicated family support was important to their efforts to take
medication, eat better and try to be physically active.
 “I love junk food, but my husband does not let me eat it.”
 “My granddaughter or daughter will call me and ask, Nana did you take
your medicine?”
 Identified the areas of self-care management with which they needed
assistance to improve their health outcomes.
 “It is easy for them to tell you what you need to do, but hard for you to do
it.”
 “Eating right, exercising , reducing stress…”
 “Some of the pills make you nauseous and/or sleepy.”
Intervention:
RN Care Managers coached patients
on their selected self–management goals
 Reducing stress
 Statistically significant
 Exercise
increase in selfmanagement goals related
to stress, exercise and
nutrition (p=>.0001)
 No significant increase in
self-management goals
related to smoking.
 Nutrition
Statistically significant
kept 18 mo. face to
improvement  38/116
face appointment
 69/116 kept 6 mo. face to
face appointment
 LDL (p=.002)
 Number of cigarettes smoked
(p=<.0001)
 80/116 kept 12 mo. face to
face appointment
 LDL (p=.03)
 Systolic blood pressure
(p=.001)
 Diastolic blood pressure
(p=.001)
A longer term impact,
consistent with selfmanagement of stress,
nutrition and exercise.
 Number of cigarettes smoked
(p=.03)
Above consistent with selfmanagement of stress,
nutrition and exercise.
Improvement in LDL and number
of cigarettes smoked not
significant.
Clinically significant outcome measures
baseline to 12 and 18 mos.
 Body Mass Index
 39 % had reduced BMI at
12 months and
 60% at 18 months
 Hemoglobin A1C
 47% had reduced A1C at
12 months and
 25% at 18 months
SF 12 Outcome Measures:
Pre- vs. Post-intervention
 Medical Outcomes Short Form measures perceptions of the patient’s
own health to include: general health, physical functioning, bodily
pain, vitality, social functioning, role limitation physical, role limitation
emotional, physical health and mental health.
 Subjects had statistically significant positive changes in bodily pain
(p<.0001), role limitation emotional (p<.0001), social functioning
(p=.003)and mental health (p=.0004).
 Consistent with statistically significant increase in self-management
goals related to stress and RN Care Managers reporting selfmanagement goals relating to stress were primary prior to patients
being able to think about other goals.
Post-intervention
patient focus groups:
 Expressed better understanding of medication use, diet and self
management of diabetes, hypertensions and lipid levels because RN
Care Manager took time with them and helped patients to set monthly
goals.
 “Because I didn’t have a clue what was going on with being a diabetic and
you really took time out to help me.”
 “You helped me out with my smoking. I am down to half a pack per day.”
 Meeting one on one with RN Care Managers provided very personal
individualized assistance in taking small steps to improve their health
over time.
 “My cholesterol is really good. Like I was shocked when my heart doctor
told me it was perfect because it was sky high.”
 “Yeah, me with the junk food and I stopped. I drink water and I eat alot of
vegetables and fruit.”
 Both parents and children supported patients efforts to take
medication, reduce their stress, eat better, decrease or stop smoking
and to be more physically active.
 “All of my family stopped smoking.”
 My mother started buying more healthy stuff for the house.”
 RN Care Managers and clinic staff are encouraging and caring, when
you have insurance and when you do not.
 “I love this clinic and program, because a few months ago my insurance ran
out. No one would provide my medicine but here the nurse practitioner
went to the back and gave me some. ”
 “The RN Care Manager is very dedicated and sincere. I feel it is more than
just a program to her.”
Challenges
 African American Women in the study were residents of
public housing or homeless
 Uninsured or had Medicaid insurance
 Auditing the records of the low income women in this
study provides a continuing context for understanding the
complexity of their lives, primarily related to exposure to
infectious diseases (STDS and TB), violence, physical
abuse, emotional abuse, substance abuse, loss of
employment and homelessness.
Success and Future Direction
 In spite of the complexity of their lives, the women responded
positively to selecting their own self-management goals and being
supported with individualized coaching from RN Care Managers.
 Public Health Management Corporation, owner of these two nurse-led
NCQA recognized PCMHs, is committed to continue to provide
support for patients to meet their selected self-management goals.
 This study provides evidence of the need for a longitudinal study with a
larger sample size over at least three years to evaluate the impact of this
intervention on achieving and maintaining outcome goals and
documenting the cost per patient for the intervention.
Acknowledgements
Project was conducted in collaboration with:
the National Nursing Centers Consortium, Public
Health Management Corporation, Temple University
and the American Nurses Association and Pfizer, Inc.
who also in part provided financial support for
the study.
Contact information
 Nancy L. Rothman, EdD, RN
Independence Foundation Professor of Urban Community Nursing
Temple University
[email protected]
215-707-5436