Implementation of a diabetes clinic‐in‐a‐clinic project in a family practice setting: using the plan,do, study,act model

Objectives. The American Association of Diabetic Educators suggests that educating patients about their diabetes management facilitates problem solving and coping skills. This paper will describe a clinic‐in‐a‐clinic model of care delivery founded on the principles of the Chronic Care Model and focused towards the outcomes proposed by the American Association of Diabetic Educators. The reader will be introduced to the use of the ‘plan, do, study, act’ process used to develop this model in a clinical setting. Background. Self‐management support, a key component of the Chronic Care Model, focuses on providing patients with the skills to make healthcare decisions. Self‐management encourages patient to be responsible for his/her own health care. Because diabetes outcomes and complication prevalence are related to the degree of self involvement in illness care, self‐management support is an important component of disease management. Design. Plan, do, study, act model for program development. Methods. The ‘plan, do, study, act’ cycles outlined the steps needed to implement the clinic‐in‐a‐clinic program with success related to coordination of all components and continual assessment and revision. Each cycle was initiated in a sequential order allowing for evaluation and goal adjustment before the next cycle was implemented. Conclusions. The majority of patients seen were middle‐aged, obese, females with HbA1cs greatly above the recommended 7·0. Patients selected a variety of topics related to diabetes management for their clinical session. Participation rates were consistent with regular clinic visit attendance. Barriers to success of the program were related to both structure and process. Relevance to clinical practice. The clinic‐in‐a‐clinic design moves disease management from individual practice into a property of the health systems and places importance on the collaboration of patient, provider and delivery system in reducing the consequences of chronic illness. Use of the ‘plan, do, study, act’ cycle model offers a method for changing the process of care delivery in a structured, sequential approach.     

The Community-Based Transitions Model: one agency's experience

Home care providers have more than a century of experience providing complex patient care and medication management, symptom management, and disease self-management. These requisite home care clinician skills are common to those described of the "health coach" in most contemporary care transition models. When home care clinicians are re-tooled with health coaching competencies such as motivational interviewing, their role as the "perfect" health coach can be readily demonstrated. The Community-Based Transitions Model? (CBTM) was developed by home care providers to equip clinicians with these additional skills and to address gaps in all care transitions along the chronic condition trajectory. This agency's experience with this model is described.     

Preventing avoidable hospitalizations

To reduce avoidable hospital readmissions and improve transitions between healthcare settings, Virtua Home Care implemented a Transitions of Care Program based on the Transitional Care Model developed at the University of Pennsylvania School of Nursing. Home care nurses were educated to be transitional care nurses and provided intensive education and follow-up for patients with chronic diseases who were identified as having a high risk of readmission. This program, which provides services to patients enrolled in fee-for-service (FFS) Medicare and who are eligible to receive the home health benefit, has successfully reduced hospital readmissions. This article describes Virtua Home Care's journey in adapting and implementing an evidence-based care transitions model.     

Palliative care management: a Veterans Administration demonstration project

As part of a Veterans Health Administration (VA) commitment to improve end-of-life care the VA Greater Los Angeles Healthcare System (GLA) implemented Pathways of Caring, a 3-year demonstration project targeting patients with inoperable lung cancer and advanced heart failure and chronic lung disease. The program utilized case-finding for early identification of poor-prognosis patients, interdisciplinary palliative assessment, and intensive nurse care coordination to optimize symptom management, continuity and coordination of services across providers and care settings, and support for families. Program evaluation used patient and family surveys as well as reviews of medical records and administrative databases to assess processes and outcomes of care. Despite significant programmatic challenges including organizational instability and evaluation design issues, the program achieved measurable success including high rates of advance care planning, hospice enrollment, and death at home, and low end-of-life hospital and Intensive Care Unit (ICU) use. As a result of its success, the program will be expanded and its care model extended institution-wide.     

Complex adaptive chronic care

Background The Chronic Care Model (CCM) is widely taken up as the universal operational framework for redesigning health systems to address the increasing chronic disease burden of an ageing population. Chronic care encompasses health promotion, prevention, self management, disease control, treatment and palliation to address ‘chronicity’ of long journeys through disease, illness and care in the varying contexts of complex health systems. Yet at an operational level, CCM activities are predominantly based on an evidence‐base of discreet chronic disease interventions in specific settings; and their demonstrable impact is limited to processes of select disease management such as diabetes in specific disease management programs. Aims This paper proposes a framework that makes sense of the nature of chronicity and its multiple dimensions beyond disease and argues for a set of building blocks and leverage points that should constitute the starting points for ‘redesign’? Findings Complex Adaptive Chronic Care is proposed as an idea for an explanatory and implementation framework for addressing chronicity in existing and future chronic care models. Chronicity is overtly conceptualized to encompass the phenomena of an individual journey, with simple and complicated, complex and chaotic phases, through long term asymptomatic disease to bodily dysfunction and illness, located in family and communities. Chronicity encompasses trajectories of self‐care and health care, as health, illness and disease co‐exist and co‐evolve in the setting of primary care, local care networks and at times institutions. A systems approach to individuals in their multi‐layered networks making sense of and optimizing experiences of their chronic illness would build on core values and agency around a local vision of health, empowerment of individuals and adaptive leadership, and it responds in line with the local values inherent in the community's disease‐based knowledge and the local service's history and dynamics. Complex Adaptive Chronic Care exceeds the current notions of disease management as an endpoint. Primary care team members are system adaptors in partnership with individuals constructing their care and system leadership in response to chronic illness, and enable healthy resilience as well as personal healing and support. Outcomes of complex adaptive chronic care are the emergence of health in individuals and communities through adaptability, self‐organization and empowerment. Discussion Chronic care reform from within a complex adaptive system framework is bottom up and emergent and stands in stark contrast to (but has to co‐exist with) the prevailing protocol based disease care rewarding selective surrogate indicators of disease control. Frameworks such as the Chronic Care Model provide guidance, but do not replace individual experience, local adaptive leadership and responsiveness. The awareness of complexity means opening up problems to a different reality demanding different set of questions and approaches to answer them.     

Finding common ground: patient-centeredness and evidence-based chronic illness care

Health outcomes for patients with major chronic illnesses depend on the appropriate use of proven pharmaceuticals and other therapeutic technologies, and effective self-management by patients. Effective chronic illness care then bases clinical decisions on the best, rigorous scientific evidence, or evidence-based medicine. Effective support for patient self-management includes efforts to increase patient participation in care and collaborative goal-setting and planning of treatment. These interventions appear somewhat consistent with recent conceptualizations of patient-centered care. The consistent delivery of proven therapies and information and support for self-management requires practice systems organized for that purpose. The Chronic Care Model is a compilation of those practice system changes shown to improve chronic care. This paper explores the concept of patient-centeredness and its relationship to the Chronic Care Model. We conclude that the Model is both evidence-based and patient-centered and that these can be properties of health systems, and not just of individual practitioners.     

Managing Chronic Disease in Affordable Primary Care

National agencies are calling for quality improvement in primary care health care services and across the United States health care system. Changes would be directed toward improving quality of life for the chronically ill and decreasing their financial burden and that placed on society. Nurse practitioners, based on their expertise and preparation in patient education, are ideal health care providers to establish partnerships with motivated, informed, chronically ill patients and to promote change in health care policy, guidelines, and meeting patient educational needs. Within worksite primary care, nurse practitioners can, through the Chronic Care Model framework, provide chronic disease management and affordable health care access.     

Case management and the chronic care model: a multidisciplinary role

The core functions of case management, assessment, planning, linking, monitoring, advocacy, and outreach assume a new perspective in the context of systems that have adopted the Chronic Care Model. This article considers case management through the experience of three systems that have implemented the Chronic Care Model. A movement toward condition neutral case management, focused on care that is more wholly patient centric, is also examined.     

Chronic care management for the elderly: an opportunity for gerontological nurse practitioners

PURPOSE: To discuss the role that gerontological nurse practitioners (GNPs) may play in providing chronic care management for the elderly. DATA SOURCES: Review of recent literature on chronic care management, personal experience of the authors in caring for older adults under the chronic care management model, and a case study. CONCLUSIONS: GNPs are the most appropriate practitioners to provide and coordinate chronic care management to the population that needs it most--the elderly. IMPLICATIONS FOR PRACTICE: Demographic shifts in the United States have increased the number of people with chronic illnesses; however, the nation's healthcare delivery system has not significantly evolved to meet the changing needs of its population. As a result, many people, especially older adults, suffer needlessly, and healthcare costs continue to rise. Chronic care management may alleviate older adults' chronic health problems, reduce expenditures for their health care, and promote their satisfaction and quality of life.     

Applying the Chronic Care Model in a Free Clinic

Uninsured patients with diabetes are less likely than insured patients to receive recommended care and access the appropriate chronic care management programs, resulting in poorer outcomes. A pilot program using the Chronic Care Model framework was implemented to determine its effectiveness in improving clinical and self-management outcomes of high-risk patients with diabetes attending a free clinic for the uninsured. A comparison of baseline and posttest findings showed a statistically significant reduction in hemoglobin A1c. Although not statistically significant, downward trends were observed in blood pressure, triglycerides, and low-density lipoprotein levels. All patients had documented self-management goals and reported high satisfaction with the program. These findings suggest that programs guided by the Chronic Care Model have the potential to improve clinical outcomes and self-management skills of uninsured patients with diabetes.     

Interprofessional care of people with multiple chronic conditions: An open-access resource for nursing educators

Nurses, nurse practitioners, and other healthcare professionals must be prepared to care for the growing population of patients with multiple chronic conditions, to promote patient engagement, patient self-management, and for interprofessional collaboration. Interprofessional Care of Individuals with Multiple Chronic Conditions is an open-access eLearning course designed to prepare students with these skills. The course features multimedia presentations, interactive exercises, and an immersive “day in the life of a patient-centered medical home” in which learners make decisions, receive feedback, and experience consequences in the context of real-world video scenarios. Three hundred thirty-four nurse practitioner students participated in the educational program. To evaluate the program, we conducted a paired-samples t-test to compare scores on pre and posttest evaluation surveys. There was a significant difference in the scores for applying the Chronic Care Model t (df) = 15.99; p < 0.001, coaching for self-management t (df) = 11.04; p < 0.001 and interprofessional collaboration t (df) = 3.86; p < 0.00. The majority of students were satisfied or very satisfied with the modules. Students found the immersive video scenarios to be the best feature of the course. The course is available to assist students in gaining the ability to care for patients with chronic illnesses within interprofessional practice settings.     

A survey of leading chronic disease management programs: are they consistent with the literature?

Caring for patients with chronic illness in an era of cost constraints and performance monitoring has led to a sharp growth in "disease management" efforts by health systems utilizing internal innovators or outside firms. This paper describes surveys and site visits of the chronic disease management activities of 72 programs nominated by experts in the field of chronic illness care as being particularly innovative and effective. The survey and analysis were guided by a Model for Effective Chronic Illness Care derived from a process of literature synthesis and expert review. The model proved to be useful in describing the characteristics consistently shared by successful programs, and the surveys indicated common barriers to further expansion of innovative pilot programs. The survey indicated that most of the nominated programs were limited in their effectiveness and reach by their reliance on traditional patient education, rather than modern self-management support, poor linkages to primary care, and reliance on referrals rather than population-based approaches.     

Levels of personhood: a model for dementia care

"Personhood" is a concept that may be seen as insignificant to health care delivery, yet it has strong relevance to people suffering from dementia in nursing home settings. When the dementia disease process negatively affects residents' cognition, memory, and the ability to communicate effectively, nursing home caregivers may approach care in a paternalistic manner, similar to a parent's authority over a child. Based on attributes of personhood identified in the literature, 3 levels of personhood are defined, discussed, and related to the naturally occurring dementia disease progression. Challenges to, and benefits of, the promotion of personhood in current nursing home dementia care are discussed. The author proposes a Personhood Model for Dementia Care that is based on the 3 identified levels of personhood. The model provides a structure for organizing existing person-centered interventions and strategies in dementia care. In addition, the proposed model provides a framework for understanding and testing the potential value and significance of future person-centered interventions as they are developed and implemented.     

Role of primary care in early diagnosis and effective management of COPD

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a common multi-component disease that imposes an enormous burden on the patient, the healthcare professional and the society in terms of morbidity, mortality, healthcare resource utilisation and cost. Despite the availability of several comprehensive treatment guidelines, COPD is both under-diagnosed and misdiagnosed. Some of the factors contributing to this are a poor knowledge and low adherence to guideline recommendations, on the part of some healthcare professionals, and a lack of understanding of the significance and severity of the disease, on the part of patients. However, evidence suggests that COPD is both preventable and treatable when it is diagnosed early and treated effectively. Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines suggest that the key to early diagnosis is the recognition of the clinical features of persistent cough, chronic sputum production, breathlessness on exertion and a history of exposure to tobacco smoke. Primary care clinicians can play a crucial role in early diagnosis of at-risk subjects. They can educate patients to recognise the early symptoms of COPD, avoid the risk factors, such as smoking, and encourage early presentation to a primary care professional. Similarly, evidence suggests that effective implementation of non-pharmacological and pharmacological interventions can improve the management of COPD patients at the primary care level. OBJECTIVES: The aim of this review is to discuss the role of the primary care team in the early diagnosis and effective management of COPD, and to outline education initiatives and management strategies that can be implemented in primary care.     

Understanding the perspectives of care home managers when managing care of residents living with frailty

Identification of frailty is an increasingly prominent concept in healthcare policy that drives access to services and support, and frailty is common amongst care home residents. Care home managers play a central role in facilitating residents’ access to healthcare, but utility and relevance of the term ‘frailty’ for care home managers, is unknown. In this exploratory qualitative study we used semistructured interviews to explore care home managers' perspectives of frailty and how that understanding influences residents’ care. We found ‘frailty’ was not specific enough to be useful in a context where many are frail and individualised care is requisite. Care home managers’ perceptions of their key role, holistic assessment of residents and facilitating access to external expertise, aligns with best practice guidelines on frailty care. If the term ‘frailty’ does not provide a common language for all caregivers and service providers, inequitable care of people with frailty may arise.     

Global case management: using the case management model for the care of patients with acute myocardial infarction in a military hospital in Turkey

This study was planned in an experimental manner to use the "case management model" for the care of patients with acute myocardial infarction (MI), and to determine the effect of this method on the quality of care, patient and nurse satisfaction, and the patient's inpatient duration at the hospital. Data for the study were obtained using the Patient Information Form, Acute MI Care Protocol (Clinical Pathway), Care Monitoring Scale and Scoring Form, Acute MI Nursing Care Plan, Patient Education Booklet, and a Patient and Nurse Satisfaction Evaluation Survey. Evaluation results showed that the patient group where the case management model was used had increased quality of care, decreased inpatient stay, and increased satisfaction of the patient and the nurse. Therefore, it was suggested that the case management model be used in healthcare institutions in Turkey, care protocols for various diagnoses be developed, and nurses should be trained as case managers to increase the quality of care at healthcare institutions.     

Adults with sickle cell disease: an interdisciplinary approach to home care and self-care management with a case study

The complexity of caring for adults with sickle cell disease (SCD) strains the confines of a care-segregated medical system. As treatment protocols have dramatically improved since 1990, many patients with SCD are now living well beyond their 6th decade of life. This improved survival rate presents opportunities and challenges for the home healthcare nurse in the management of adult patients with SCD. The home healthcare nurse is essential in the coordination of interdisciplinary health team members to reduce pain episodes and the potentially catastrophic complications of renal failure, pulmonary disease, and cardiovascular events. In addition, the home healthcare nurse serves as patient advocate for the transition from acute care to home, as well as advocate for healthcare maintenance of vision, musculoskeletal involvement, and social and psychological support. This article seeks to provide a viable network for home healthcare nurses to establish self-care management and support of the adult patient with SCD.     

In-home wound care management utilizing information technology

Chronic wounds are a major healthcare crisis, presenting challenges for home health agencies lacking specially trained staff to properly monitor and manage these wounds. Consequently, the home health industry needs to improve wound management methods and technologies to properly care for patients with chronic wounds. Saint Francis University's Center of Excellence for Remote and Medically Under-Served Areas partnered with a home health agency (University of Pittsburgh Medical Center Lee Regional Community Nursing Service) to identify a solution to this problem.     

Disease management: a new and exciting opportunity in home healthcare

Disease management programs are beginning to encompass providers across the healthcare continuum, including home healthcare. The premise behind disease management is that coordinated, evidence-based interventions can be applied to the care of patients with specific high-cost, high-volume chronic conditions, resulting in improved clinical outcomes and lower overall costs. Outcomes data (actual results) are central in this approach to patient care.