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

2. 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

3. 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

4. Objectives ♦ Apply lessons learned to current nursing practice and care coordination efforts in light of the Affordable Care Act. 4

5. 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 5

6. Application to Vulnerable/Safety Net Populations ♦ Safety net/vulnerable populations ♦ May not have primary care provider ♦ ER Use for primary care ♦ Hospitalizations 6

7. % of adults with diabetes greatest among those with least education & lowest household income (Nebraska DHHS, 2012; CDC, 2011) Diabetes: Nebraska Adults (18 & older) 7

8. Diabetes: Cost 8 ADA, 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 ♦ 7 th 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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 15

16. 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 16 Hays, Sather & Peters, 1999; Kaiser, 2012

17. 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 17 Barry, Kaiser, & Atwood, 2007; Radosevich & Pruitt, 1996

18. 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

19. 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

20. 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 20 Adapted from Anderson & Christison-Lagay, 2008; Lorig et al., 2006

21. 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

22. 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 22

23. 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

24. 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

25. 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

26. CHIRS Results Average CHIRS Total Scores Time 1Time 2Time 3Time 4 Mean31.432.930.531.5 SD6.56.36.87.7 Range17-4719-4719-3919-42 n28 14 26

27. 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

28. 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

29. HSQ-12 Results – Entire Sample Time 1 (n=28)Time 2 (n=15) HSQ-12 Total Score Mean483.6469.8 SD173.8165.4 Range120-745192-754 HSQ-12 Physical Score Mean223.6207.4 SD93.697.6 Range35-40035-385 HSQ-12 Mental Score Mean260.0262.4 SD95.284.5 Range85-400117-380 29

30. HSQ-12 Results – Time 1 vs. Time 2 Time 1 (n=15) Time 2 (n=15)p-value* HSQ-12 Total Score Adjusted Mean*462.0469.80.32 SD195.0165.4 HSQ-12 Physical Score Adjusted Mean212.8207.40.36 SD103.197.6 HSQ-12 Mental Score Adjusted Mean249.2262.40.93 SD103.984.5 * Based on analysis of covariance (ANCOVA) controlling for the number of days between time 1 and time 2 (average number of days = 156) 30

31. PHQ-9 Results Time 1Time 2 Level of Depression#%#% None933.3426.7 Mild725.9640.0 Moderate414.8533.3 Moderately Severe518.500 Severe27.400 31

32. PHQ-9 Results – Entire Sample Time 1 n=27 Time 2 n=15 Mean8.57.6 SD6.94.6 Range0-230-16 Time 1 n=14 Time 2 n=14p-value* Adjusted Mean*9.57.00.06 SD6.74.1 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

33. DES Results – Entire Sample Time 1 n=28 Time 2 n=15 Mean4.34.4 SD.6 Range2.9-5.03.4-5.0 Time 1 n=14 Time 2 n=14p-value* Adjusted Mean*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

34. Action Plan Results Indicated this Activity as a GoalConfidence Goals Met None of the time # % Less than 50% of the time # % More than 50% of the time # % All of the time # % #%MeanSD Exercise6343%8.571.6713.6%725.0%1450.0%621.4% Diet4128%7.311.790531.3%956.3%212.5% Blood Sugar2417%7.752.370333.3%222.2%444.4% Feelings64%9.002.83133.3%1 1 Foot Checks53%8.002.45 1 100.0 % Meds43%7.672.52 133.3%1 1 Smoking21%9.001.41 150.0% 1 34

35. 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

36. 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) 36

37. 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)

38. 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

39. 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

40. 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

41. 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

42. References Adams, K., & Corrigan, J. M. (Eds.) (2003). Institute of Medicine. Priority areas for national 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. American Diabetes Association. (2013). The cost of diabetes. Retrieved April 1, 2013 from http://www.diabetes.org/advocate/resources/cost-of-diabetes.html http://www.diabetes.org/advocate/resources/cost-of-diabetes.html Barlow, J., Wright, C., Sheasby, J., Turner, A., & Hainsworth, J. (2002). Self-management approaches for people with chronic conditions: a review. Patient Education and Counseling, 48, 177-187. 42

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