A randomized controlled trial of a nurse-led case management programme for hospital-discharged older adults with co-morbidities

Susan Ka Yee Chow, Frances Kam Yuet Wong, Susan Ka Yee Chow, Frances Kam Yuet Wong

Abstract

Aim: To examine the effects of a nurse-led case management programme for hospital-discharged older adults with co-morbidities.

Background: The most significant chronic conditions today involve diseases of the cardiovascular, respiratory, endocrine and renal systems. Previous studies have suggested that a nurse-led case management approach using either telephone follow-ups or home visits was able to improve clinical and patient outcomes for patients having a single, chronic disease, while the effects for older patients having at least two long-term conditions are unknown. A self-help programme using motivation and empowerment approaches is the framework of care in the study.

Design: Randomized controlled trial.

Method: The study was conducted from 2010-2012. Older patients having at least two chronic diseases were included for analysis. The participants were randomized into three arms: two study groups and one control group. Data were collected at baseline and at 4 and 12 weeks later.

Results: Two hundred and eighty-one patients completed the study. The interventions demonstrated significant differences in hospital readmission rates within 84 days post discharge. The two intervention groups had lower readmission rates than the control group. Patients in the two study arms had significantly better self-rated health and self-efficacy. There was significant difference between the groups in the physical composite score, but no significant difference in mental component score in SF-36 scale.

Conclusion: The postdischarge interventions led by the nurse case managers on self-management of disease using the empowerment approach were able to provide effective clinical and patient outcomes for older patients having co-morbidities.

Keywords: co-morbidities; hospital readmission; nurse-led case management; older adults; randomised control trial; self-efficacy.

© 2014 The Authors. Journal of Advanced Nursing Published by John Wiley & Sons Ltd.

Figures

Figure 1
Figure 1
CONSORT diagram of the trial flow.

References

    1. Bandura A. Self-efficacy: towards a unifying theory of behavioral change. Psychological Review. 1977;84:191–215.
    1. Bardach SH. Schoenberg NE. Primary care physician counseling with patients with multiple morbidity. Qualitative Health Research. 2012;22:1599–1611.
    1. Beverly EA, Wray LA, Chiu CJ. Weinger K. Perceived challenges and priorities in co-morbidity management of older patients with Type 2 diabetes. Diabetic Medicine. 2011;28:781–784.
    1. Census and Statistics Department. Thematic Household Survey Report No. 40. Hong Kong: Census and Statistics Department; 2009.
    1. Chen Y. Li IC. Effectiveness of interventions using empowerment concept for patients with chronic disease: a systematic review; Effectiveness of Nurse Practitioners in nursing homes: a systematic review; Effectiveness of strategies to promote safe transition of older people across care settings; Management of disruptive behaviour within nursing work environments: a comprehensive systematic review of the evidence. Journal of Advanced Nursing. 2009;66:1446–1451.
    1. Chow SKY. Chan WC. Depression: problem-solving appraisal and self-rated health among Hong Kong Chinese migrant women. Nursing and Health Sciences. 2010;12:352–359.
    1. Chow SKY. Wong FKY. Health-related quality of life in patients undergoing peritoneal dialysis: effects of a nurse-led case management programmed. Journal of Advanced Nursing. 2010;66:1780–1792.
    1. Chow SKY. Wong FKY. The reliability and validity of the Chinese version of the short-form chronic disease self-efficacy scales for older adults. Journal of Clinical Nursing. 2013 doi: .
    1. Clark NM, Becker MH, Janz NK, Lorig K, Rakowski W. Anderson L. Self-management of chronic disease by older adults: a review and questions for research. Journal of Aging and Health. 1991;3:3–27.
    1. Clark R, Inglis SC, McAlister FA, Cleland J. Stewart S. Telemonitoring or structured telephone support programmes for patients with chronic heart failure: systematic review and meta-analysis. British Medical Journal. 2007;334:942–945.
    1. Cutilli CC. Health literacy in geriatric patients: an integrative review of the literature. Orthopedic Nursing. 2007;26:43–48.
    1. DeSalvo KB, Boser N, Reynolds K, He J. Muntner P. Mortality prediction with a single general self-rated health question. A meta-analysis. Journal of General Internal Medicine. 2005;20:267–275.
    1. Frich LMH. Nursing interventions for patients with chronic conditions. Journal of Advanced Nursing. 2003;44:137–153.
    1. Fukuyama F. Social capital, civil society and development. Third World Quarterly. 2001;22:7–20.
    1. Gallagher R, Donoghue J. Stein-Parbury J. Self-management in older patients with chronic illness. International Journal of Nursing Studies. 2008;14:373–382.
    1. Garcia-Olmos L, Salvador CH, Alberquilla A, Lora D, Carmona M, Garcia-Sagredo P, Pascual M, Munoz A, Monteagudo JL. Garcia-Lopez F. Comorbidity patterns in patients with chronic diseases in general practice. PLoS One. 2012;7:1–7.
    1. Gill TM, Baker DI, Gottschalk M, Gahbauer EA, Charpentier PA, de Regt PT. Wallace SJ. A prehabilitation program for physically frail community-living older persons. Archives of Physical Medicine and Rehabilitation. 2003;84:394–404.
    1. Glendinning C. Breaking down barriers: integrating health and care services for older people in England. Health Policy. 2003;65:139–151.
    1. Hospital Authority, Hong Kong (n.d.) Hospital Authority Statistical Report (2010–2011) Retrieved from on 15 March 2013.
    1. Kawachi I, Subramanian SV. Kim D. Social Capital and Health. New York: Springer; 2008. pp. 1–26.
    1. Kennedy A, Reeves D, Bower P, Lee V, Middleton E, Richardson G, Gardner C, Gately C. Rogers A. The effectiveness and cost effectiveness of a national lay-led self care support programme for patients with long-term conditions: a pragmatic randomised controlled trial. Journal of Epidemiology and Community Health. 2007;61:254–261.
    1. Kwok T, Lum CM, Chan HS, Ma HM, Lee D. Woo J. A randomized, controlled trial of an intensive community nurse-supported discharge program in preventing hospital readmission of older patients with chronic lung disease. The American Geriatrics Society. 2004;52:1240–1246.
    1. Kwok T, Lee J, Woo J, Lee DTF. Griffith S. A randomized controlled trial of a community nurse-supported hospital discharge programme in older patients with chronic heart failure. Journal of Clinical Nursing. 2008;17:109–117.
    1. Lam CLK. Gandek B. Cross-cultural adaptation of the SF-36 and SF-12. Quality of Life Research. 2001;10:283.
    1. Lattimer C. When it comes to transitions in patient care, effective communication can make all the difference. Journal of the American Society on Aging. 2011;35:69–72.
    1. Lupari M, Coatges V, Adamson G. Crealey GE. ‘We're just not getting it right’ – how should we provide care to the older person with multi-morbid chronic conditions. Journal of Clinical Nursing. 2011;20:1225–1235.
    1. Martin K. The Omaha System: A Key to Practice, Documentation and Information Management. 2. St, Louis, MO: Elsevier Saunders; 2005.
    1. Mattke S, Seid M. Ma S. Evidence for the effect of disease management: is $1 billion a year a good investment? American Journal of Managed Care. 2007;13:670–676.
    1. McAllister M, Dunn G, Payne K. Todd C. Patient empowerment: the need to consider it as a measurable patient-reported outcome for chronic conditions. BMC Health Services Research. 2012;12:157–164.
    1. Mistiaen P. Poot E. Telephone follow-up, initiated by a hospital-based health professional, for postdischarge problems in patients discharged from hospital to home. Cochrane Database Syst Rev. 2008:4.
    1. Naylor M, Brooten D, Campbell R, Maislin G, McCauley KM. Schwartz S. Transitional care of older adults hospitalized with heart failure: a randomized controlled trial. Journal of the American Geriatrics Society. 2004;52:675–684.
    1. Norris SL, High K, Gill TM, Hennessy S, Kutner JS, Reuben DB, Unutzer J. Landefeld CS. Health care for older Americans with multiple chronic conditions: a research agenda. Journal of the American Geriatrics Society. 2008;56:149–159.
    1. Ose D, Miksch A, Urban E, Natanzon I, Szecsenyi J, Kunz CU. Freund T. Health related quality of life and comorbidity. A descriptive analysis comparing EQ-5D dimensions of patients in the German disease management program for type 2 diabetes and patients in routine care. BMC Health Services Research. 2011;11:179.
    1. Peikes D, Chen A, Schore J. Brown R. Effects of care coordination on hospitalization, quality of care and health care expenditures among medicare beneficiaries. JAMA. 2009;301:603–618.
    1. Radhakrishnan K. The efficacy of tailored interventions for self-management outcomes of type 2 diabetes, hypertension or heart disease: a systematic review. Journal of Advanced Nursing. 2011;68:496–510.
    1. Schulz KF, Altman DG. Moher D for the CONSORT Group. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomized trials. Annals of Internal Medicine. 2010;152:1–8.
    1. Sutherland D. Hayter M. Structured review: evaluating the effectiveness of nurse case managers in improving health outcomes in three major chronic diseases. Journal of Clinical Nursing. 2009;18:2978–2992.
    1. Vogeli C, Shields AE, Lee TA, Gibson TB, Marder WD, Weiss KB. Blumenthal D. Multiple chronic conditions: prevalence, health consequences and implications for quality, care management and costs. Journal of General Internal Medicine. 2007;22(Suppl 3):391–395.
    1. Ware JE. SF-36 Literature Construction of the SF-36 Version 2.0 Psychometric Considerations Translations Discussion. Retrieved from . retrieved on 29 May 2013.
    1. Wen M, Hawkley LC. Cacioppo JT. Objective and perceived neighbourhood environment, individual SES and psychosocial factors and self-rated health: an analysis of old adults in Cook County, Illinois. Social Science & Medicine. 2006;63:2575–2590.
    1. Williams A. Patients with comorbidities: perceptions of acute care services. Journal of Advanced Nursing. 2004;46:13–22.
    1. Wong FKY, Ho ML, Chiu I, Lui WK, Chan C. Lee KM. Factors contributing to hospital readmission in a Hong Kong regional hospital: a case-controlled study. Nursing Research. 2002;51:40–49.
    1. Wong FKY, Chow SKY, Chung L, Chang K, Chan T, Lee WM. Lee R. Can home visits help reduce hospital readmissions? Randomized controlled trial. Journal of Advanced Nursing. 2008;62:585–596.
    1. Wong FKY, Chow SKY. Chan T. Evaluation of a nurse led disease management programme for chronic kidney disease management: a randomized controlled trial. International Journal of Nursing Studies. 2010;47:268–278.
    1. Wong FKY, Ho ML, Yeung SY, Tam SK. Chow SKY. Effects of a health-social partnership transitional program on hospital readmission: a randomized controlled trial. Social Science & Medicine. 2011;73:960–969.
    1. Wong FKY, Chow SKY, Chan TMF. Tam SKY. Comparison of effects between home visits with telephone calls and telephone calls only for transitional discharge support: a randomised controlled trial. Age and Ageing. 2013 doi: .
    1. Wun YT, Chan K. Lee A. Co-morbidity in general practice. Family Practice. 1998;15:266–268.
    1. Yach D, Hawkes C, Gould L. Hofman KJ. The global burden of chronic diseases overcoming impediments to prevention and control. The Journal of the American Medical Association. 2004;291:2616–2622.
    1. Yamamoto PPE. Improving the oral health of older people: the approach of the WHO global oral health programme. Community Dentistry and Oral Epidemiology. 2005;33:81–92.

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