Chronic disease management in the older adult

Presented by Stephanie Thompson, RN

Chronic Disease

Management in the

Older Adult

What is Chronic Disease Management?

A “comprehensive, integrated approach to the

care and reimbursement of high cost chronic

illnesses” through management and treatment of

the disease.

(Marquis and Huston, 2012)

Goal of Chronic Disease Management

The main goal of chronic disease management is to

address chronic disease in an economically efficient and

integrated manner that provides the best patient outcomes.

Over 2 trillion is spent in the United States annually.

95% of this is direct patient medical care for older adults.

Cost of Chronic Disease Management

(Kapustin, 2010)

Is Chronic Disease Management

Relevant to Older Adults?

80% of older adults have at least one

chronic disease that they are trying to

manage at home either alone or with the

assistance of family members.

YES !!!

(Healthy Aging, 2011)

My Intention

Chronic disease management interests

me because I’ve seen thru my own

nursing practice that patients and

families want help managing their

chronic illnesses. There is a real desire

from them to want to learn more.

My intention is to help clinicians learn

how to help patients manage their

chronic illnesses more efficiently,

effectively and achieve better

outcomes.

Education and

patient self-

empowerment

are the keys to

chronic

disease

management.

Assessment

Build Rapport

Empower Patient

Problem Solving

Identify Barriers

Collaboration

Effective Listening

Set goals

Evaluation

Self-management support is “the

systematic provision of education and

supportive interventions to increase

patients’ skills and confidence in

managing their health problems, including

regular assessment of progress and

problems, goal setting and problem

solving support.”

(Clark et al., 2009)

Chronic Disease and

Self-Management

Support Techniques

Chronic Disease

Management and the

Nursing Process

Steps of the

Nursing Process

Assessment

Diagnosis

Outcomes / Planning

Implementation Evaluat

ion

Clinicians can use each step of

the nursing process when

utilizing the support techniques

of patient self-management.

(ANA, 2014)

Application using the

Nursing Process Assessment

A systematic,

dynamic way

to collect and

analyze data

about a client,

the first step

in delivering

nursing care.

Complete a comprehensive

assessment and history

Assess the chronic illness

Assess patient’s willingness

to change lifestyle behaviors

Assess patient’s level of

health literacy

(ANA, 2014)

Application using the

Nursing Process Diagnosis

The nurse’s

clinical

judgment

about the

client’s

response to

actual or

potential health

conditions or

needs.

Knowledge Deficit

Ineffective self-health management

Readiness for enhanced self-health

management

Readiness for enhanced knowledge

Risk for situational low self-esteem

(ANA, 2014)

Application using the

Nursing Process Outcomes /

Planning

The nurse sets

measurable

and achievable

short- and

long-range

goals.

Develop SMART goals

Specific

Measureable

Achievable

Relevant

Timing

(ANA, 2014)

(Chronic Care and Disease Management, 2010)

(Suter, Hennessey, Harrison, et al., 2008)

Example of a SMART Goal for Diabetic Patient:

I will check my blood sugar each morning before breakfast

and record the results daily for the next 7 days.

SMART Goals

should be related to their chronic disease

aimed at helping the patient understand the connection between

disease management, and their behaviors

avoid over ambitious goals

should target a specific behavior

Application using the

Nursing Process

Care is

implemented

according to

the care plan

and

documented in

the patient’s

record.

Promote change through

behavior modification

Follow SMART Goals

Keep logs

Be the patient coach

Teach about chronic illness

(ANA, 2014)

Application using the

Nursing Process Evaluation

status and the

effectiveness

of the nursing

care must be

continuously

evaluated, and

the care plan

modified as

needed.

Evaluate logs and

journals

Evaluate SMART goal

attainability

Adjust SMART goals

where needed

(ANA, 2014)

Evidenced Based Practice

Sutter Care Coordination Program

Sutter Health Sacramento-Sierra Region

(Chronic Care and Disease Management, 2010)

Used chronic care and disease management teams

of RN’s and Medical Social Workers

38 percent fewer home health care visits

Reduced emergency department visits by 13 percent

Reduced hospitalizations by 39 percent

Increased patient and caregiver understanding of

chronic disease and symptom management by using

self-management techniques including education,

lifestyle modification and goals.

Evidenced Based Practice

Self-Management Among

Socioeconomically Vulnerable Older Adults

(Clark et al., 2009)

23 older adults below 200% poverty level & no insurance

12 older adults with private health insurance.

vulnerable sample had lower educational attainment & lower

health literacy

privately insured group expressed health promotion as the

key to healthy aging and had awareness of self-management

leading to improved chronic care outcomes

The vulnerable interviewees did not have expectations for

healthy aging.

Evidenced Based Practice

The Development of a Community and Home-based

Chronic Care Management Program for Older Adults.

Objective: To evaluate a chronic care management program piloted by a

visiting nurses association

Provided educational development for nurses

Piloted encounters with patients with chronic conditions

Chronic care professional modules were used to increase nurses'

knowledge—verified with exam

Patient improvement in self-management and clinical measures

Nurses were prepared to provide effective encounters to improve

self-efficacy and clinical outcomes for older adults with chronic

conditions.

(Cooper, 2013)

Solutions for Clinicians

How to Help Your Patient Manage

Chronic Disease

Use the Nursing Process Interventions

Understand the Disease itself

Promote Self-Management

Reconcile Medications

Care Coordination: PT, OT, and ST

Increase Visits During Early Phase of New Disease

Relate behavior changes to positive outcomes

Establish Meaningful Relationship

Patient

confidence

yields

improved

outcomes

through a

more suitable

patient

decision

making

process.

(Suter, Hennessey, Harrison, et al., 2008)

Discussion Scenario

You are currently a home health nurse visiting with a newly diagnosed

diabetic patient. This is your first visit with the patient and you are unsure

what she already knows about diabetes. The patient lives with her

daughter who is a very busy single mom. Many nights, dinner consists of

fast-food meals or microwave dinners. The patient drinks sodas during

the day, but states that she drinks only water at night. She checks her

blood sugar “when she feels funny” and “she never keeps a log.”

Using the nursing process, what are some initial interventions that

you can perform to determine the patient’s level of understanding

regarding diabetes management? How can you assist her in setting

SMART goals? What SMART goals would you establish initially?

.

References

ANA. (2014). The Nursing Process. Retrieved March 19, 2014, from http://

www.nursingworld.org/EspeciallyForYou/What-is-Nursing/Tools-

You-Need/Thenursingprocess.html

Chronic Care and Disease Management | AHRQ Innovations

Exchange. (2010). Pennsylvania Homecare Association Chronic

Care and Disease Management. Retrieved February 20, 2014,

from http://www.innovations.ahrq.gov/content.aspx?id=1696

Clark, D., Frankel, R., Morgan, D., Ricketts, G., Bair, M., Nyland, K., &

Callahan, C. (2009). The meaning and significance of self-

management among socioeconomically vulnerable older

adults. Journals Of Gerontology Series B: Psychological Sciences

& Social Sciences, 63B(5), S312-9.

References

Cooper, J., & McCarter, K. (2013). Result Filters. National Center for

Biotechnology Information. Retrieved March 22, 2014, from http://

www.ncbi.nlm.nih.gov/pubmed/24387773

Healthy Aging. (2011). Centers for Disease Control and Prevention.

Retrieved March 16, 2014, from

http://www.cdc.gov/chronicdisease/resources/publications/aag/

aging.htm

Kapustin, J. (2010). Chronic Disease Prevention Across the Lifespan. The

Journal for Clinician Practitioners, 6(1), 16-24.

Marquis, B.L., & Huston, C.J. (2012). Leadership roles and

management functions in nursing: Theory & application (7th

ed.). Philadelphia: Lippincott.

References

Suter, P., Hennessey, B., Harrison, G., Fagan, M., Norman, B., & Suter, W.

(2008). Home-based chronic care. An expanded integrative model for

home health professionals.. Home Healthcare Nurse, 4(26), 222-9