Nurse-Managed Health Care Home Effectiveness Project

1. Nurse-Managed Health Care Home Effectiveness Project 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

2. Presenter Disclosures • The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: No relationships to disclose

3. 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

4. Public Health Management Corporation Nursing Network PHMC Health Connection Rising Sun Health Center

5. 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

6. 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.”

7. 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.”

8. Intervention:RN Care Managers coached patients on their selected self–management goals • Reducing stress • Exercise • Nutrition • Statistically significant increase in self-management goals related to stress, exercise and nutrition (p=>.0001) • No significant increase in self-management goals related to smoking.

9. Statistically significant improvement • 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) • Number of cigarettes smoked (p=.03) Above consistent with self- management of stress, nutrition and exercise. • 38/116 kept 18 mo. face to face appointment • Systolic blood pressure (p=.001) • Diastolic blood pressure (p=.001) A longer term impact, consistent with self- management of stress, nutrition and exercise. Improvement in LDL and number of cigarettes smoked not significant.

10. Clinically significant outcome measures baseline to 12 and 18 mos. • Body Mass Index • Hemoglobin A1C • 39 % had reduced BMI at 12 months and • 60% at 18 months • 47% had reduced A1C at 12 months and • 25% at 18 months

11. 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 self-management goals relating to stress were primary prior to patients being able to think about other goals.

12. 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.”

13. 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.”

14. 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.

15. 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.

16. 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.

17. Contact information • Nancy L. Rothman, EdD, RN Independence Foundation Professor of Urban Community Nursing Temple University rothman@temple.edu 215-707-5436