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.

2

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

Objectives

♦ Apply lessons learned to current nursing

practice and care coordination efforts in

light of the Affordable Care Act.

4

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

Application to Vulnerable/Safety Net Populations

♦ Safety net/vulnerable populations

♦ May not have primary care provider

♦ ER Use for primary care

♦ Hospitalizations

6

% of adults with diabetes greatest among those with least education & lowest household income (Nebraska DHHS, 2012; CDC, 2011)

Diabetes: Nebraska Adults (18 & older)

7

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

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

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

10

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

11

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.

12

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

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)

14

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

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

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

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

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

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

21

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

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

23

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

Sample

♦ Insurance:

♦ Uninsured (n=19) ♦ Medicare (n=6)

♦ Medicaid (n=2) ♦ Other (n=1)

♦ Pharmacy:

♦ HOPE (n=11) ♦ Commercial

(n=13)

♦ Missing (n=4)

25

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

26

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

27

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

28

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

29

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)

30

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

31

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)

32

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)

33

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%

34

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

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)

36

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)

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.

38

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

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

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

41

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