Effect of a Community-Based Nursing Intervention on Mortality in Chronically Ill Older Adults: A Randomized Controlled Trial

Coburn, Kenneth D.; Marcantonio, Sherry; Lazansky, Robert; Keller, Maryellen; Davis, Nancy

doi:10.1371/journal.pmed.1001265

Cited by 49 publications

(96 citation statements)

References 48 publications

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“…Most notably, Health Quality Partners, a non-profit disease management organization in Pennsylvania, reduced hospitalization rates and overall mortality among their enrollees, though the program did not lower total costs after discounting program fees. 33 In contrast to other programs in the demonstration, care coordinators in the Health Quality Partners program provided regular in-person interaction with their assigned patients and had close relationships with their primary care clinicians. The coordinators also focused on coordinating care transitions and medication management.…”

Section: Approach 1: Complex Case Management Embedded Within Primary mentioning

confidence: 99%

Disruptive Models in Primary Care: Caring for High-Needs, High-Cost Populations

Hochman

Asch

2017

J GEN INTERN MED

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Starfield and colleagues have suggested four overarching attributes of good primary care: Bfirst-contact access for each need; long-term person-(not disease) focused care; comprehensive care for most health needs; and coordinated care when it must be sought elsewhere.^As this series on reinventing primary care highlights, there is a compelling need for new care delivery models that would advance these objectives. This need is particularly urgent for highneeds, high-cost (HNHC) populations. By definition, HNHC patients require extensive attention and consume a disproportionate share of resources, and as a result they strain traditional office-based primary care practices. In this essay, we offer a clinical vignette highlighting the challenges of caring for HNHC populations. We then describe two categories of primary care-based approaches for managing HNHC populations: complex case management, and specialized clinics focused on HNHC patients. Although complex case management programs can be incorporated into or superimposed on the traditional primary care system, such efforts often fail to engage primary care clinicians and HNHC patients, and proven benefits have been modest to date. In contrast, specialized clinics for HNHC populations are more disruptive, as care for HNHC patients must be transferred to a multidisciplinary team that can offer enhanced care coordination and other support. Such specialized clinics may produce more substantial benefits, though rigorous evaluation of these programs is needed. We conclude by suggesting policy reforms to improve care for HNHC populations.

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Section: Approach 1: Complex Case Management Embedded Within Primary mentioning

confidence: 99%

Disruptive Models in Primary Care: Caring for High-Needs, High-Cost Populations

Hochman

Asch

2017

J GEN INTERN MED

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“…With the rapid growth of diabetes prevalence in China, the burden on health care is also increasing rapidly. Evidences have shown that the community-based management of diabetes was more effective in reducing the disease-related health problems [2,3]. Therefore, an appropriate management model for diabetes care in communities is the key for the prevention and control of diabetes.…”

Section: Introductionmentioning

confidence: 99%

Evaluation of glycemic control in patients with type 2 diabetes mellitus in Chinese communities: a cross-sectional study

Shan

Lou

et al. 2015

Clin Exp Med

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This study aimed to evaluate the glycemic levels in Chinese patients with type 2 diabetes mellitus (T2DM) and to explore the factors related to the results of glycemic control. A total of 2454 T2DM patients from 11 communities were examined for glycosylated hemoglobin levels and glycemic control options. Potential factors related to the results of glycemic control were analyzed using logistic regression. Of all the patients, 55.3 % achieved the glycemic control target of HbA1c < 7 %. Multivariate analysis showed that male sex (OR 1.345, 95 % CI 1.022-1.769; P = 0.034), higher levels of fasting blood glucose (OR 1.954, 95 % CI 1.778-2.147; P < 0.001), and low-density lipoprotein cholesterol (OR 1.181, 95 % CI 1.020-1.367; P = 0.026) were significantly associated with poor glycemic control. The complexity of antidiabetics was also associated with poor glycemic control (P < 0.05). Compared to diet and exercise, insulin injection was most strongly associated with poor glycemic control (OR 6.210, 95 % CI 4.054-9.514; P < 0.001). Male patients with higher levels of total cholesterol, lower levels of high-density lipoprotein cholesterol, or longer diabetic durations showed poor glycemic control, which was not found in female patients. Glycemic control was not satisfactory in T2DM patients of Nanjing communities. Various factors are associated with poor results of glycemic control.

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“…A nurse-led care coordination program in Doylestown, Pennsylvania has demonstrated improved outcomes and lower expenditures among Medicare beneficiaries for over 10 years. 8 This randomized control trial demonstrated a 25% lower mortality risk, and in the highest risk population-defined as ≥1 admission in the past year along with a diagnosis of heart failure, coronary disease, or COPD-a 36% reduction in Part A and B Medicare expenditures. 8,9 The early success of these and other emerging programs is guiding policy.…”

mentioning

confidence: 91%

“…8 This randomized control trial demonstrated a 25% lower mortality risk, and in the highest risk population-defined as ≥1 admission in the past year along with a diagnosis of heart failure, coronary disease, or COPD-a 36% reduction in Part A and B Medicare expenditures. 8,9 The early success of these and other emerging programs is guiding policy. An SU learning collaborative not only developed key policy recommendations, but is working at the state level to advocate for reform.…”

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confidence: 91%

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Is a Strategy Focused on Super-Utilizers Equal to the Task of Health Care System Transformation? Yes

Emeche

2015

The Annals of Family Medicine

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6T he super-utilizer (SU) strategy is pivotal to health care system transformation.1 Super-utilizers are patients with high medical costs from recurring, preventable inpatient or emergency department (ED) visits.2 Although super-utilizers represent 5% of the population, they account for 50% of health care expenditures.3 The SU strategy focuses on reducing these expenditures by reducing preventable hospital visits, employing a strategy based on data, 6 stakeholder engagement, and clinical redesign. It is clear that system transformation requires fundamental changes to produce high value care or improved outcomes at lower cost. 4 The SU strategy was developed when Dr Jeffrey Brenner translated law enforcement hotspot concepts to medicine, identifying and then allocating resources to outliers of hospital utilization in the same way police departments identify and staff high crime areas. 5Community-based care coordination is a home-visit program that connects super-utilizers with primary care and community resources, and is the crux of SU clinical redesign.2 Care coordinators (licensed practical nurse, medical assistant, or social worker) work with super-utilizers to abate social determinants that contribute to high utilization and expenditures (ie, lack of transportation, lower education, housing insecurity).Program administrators (registered nurse and program manager) and health coaches comprise the multidisciplinary care coordination team. The team is supported by a dynamic data infrastructure that identifies super-utilizers, tracks utilization and spending trends, reports outcomes, and supports continuous process improvement. The strategy aligns patients' needs and community assets through stakeholder engagement, creating partnerships between patients, teams, payers, community, and health care resources. 7In Camden, New Jersey, a study is underway to evaluate this model's outcomes and potential cost savings.One doesn't have to wait for results of the Camden study to find data supporting key elements of the SU strategy. A nurse-led care coordination program in Doylestown, Pennsylvania has demonstrated improved outcomes and lower expenditures among Medicare beneficiaries for over 10 years.8 This randomized control trial demonstrated a 25% lower mortality risk, and in the highest risk population-defined as ≥1 admission in the past year along with a diagnosis of heart failure, coronary disease, or COPD-a 36% reduction in Part A and B Medicare expenditures. 8,9 The early success of these and other emerging programs is guiding policy. An SU learning collaborative not only developed key policy recommendations, but is working at the state level to advocate for reform. 10Combined data from 3 of the programs demonstrated a 34% reduction in hospital admissions and savings of $1.2 million over 12 months. 10Health care system transformation will occur under this strategy, as a result of intentional learning 2 with implications for policy. Super-utilizers are "superdetectors," helping to clearly identify system inefficiencies...

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Effect of a Community-Based Nursing Intervention on Mortality in Chronically Ill Older Adults: A Randomized Controlled Trial

Abstract: Kenneth Coburn and colleagues report findings from a randomized trial evaluating the effects of a complex nursing intervention on mortality risk among older individuals diagnosed with chronic health conditions.

Cited by 49 publications

References 48 publications

Disruptive Models in Primary Care: Caring for High-Needs, High-Cost Populations

Disruptive Models in Primary Care: Caring for High-Needs, High-Cost Populations

Evaluation of glycemic control in patients with type 2 diabetes mellitus in Chinese communities: a cross-sectional study

Is a Strategy Focused on Super-Utilizers Equal to the Task of Health Care System Transformation? Yes

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