Does Care Coordination Reduce Emergency Room Visits and Hospitalizations in the Diabetic Elderly? S C H A R M A I N E L AWSON - BA K E R, D N P S, A PR N, F N P - BC C H AT H A M U N I V E R S I T Y D N P PRO G R A M
PICO Question Does Care Coordination Reduce Emergency Room Visits and Hospitalizations in the Diabetic Elderly?
Background Diabetes Mellitus is a growing epidemic among the elderly. As this disease continues to increase across the nation; healthcare providers are scrambling for more effective ways of improving outcomes in this vulnerable population. The concept of care coordination is one possible solution that will not only help to reduce emergency room visits and hospitalizations among the diabetic elderly, but provide solid and consistent care to a population that is sometimes forgotten.
Review of Literature Coleman et al., (2001) The results from this randomized control trial (RCT) show that patients in the intervention group who received monthly physician group visits were not only less likely to make an emergency room visit, but they were also less likely to have made multiple emergency room visits. Leveille et al., (1998) This RCT was conducted to evaluate the effectiveness of a one year chronic illness and disability prevention program on health, functioning, and healthcare utilization in frail older adults. It was concluded that community-based care coordination with primary care providers can improve function and reduce inpatient utilization in chronically ill older adults.
Review of Literature (cont.) Kobb, Hoffmann, Lodge, & Kline, (2003) Findings from this Rural Home Care Project demonstrate that care coordination enhanced by technology reduces hospital admissions, bed days of care, emergency room visits, and prescriptions as well as providing high patient and provider satisfaction. Dorr et al., (2006) Results from this study suggest that care managed patients with diabetes had 3.2% fewer hospitalizations.
Review of Literature (cont.) Chumbler et al., (2005) These researchers analyzed the differences in health care service use between 400 veterans enrolled in a care coordination program and 400 veterans who were not enrolled in a care coordination program. In the end, the care coordination program reduced pricey hospital admissions. Counsell, Callahan, Buttar, Clark, & Frank, (2006) This group of researchers developed the Geriatric Resources for Assessment and Care of Elders (GRACE) model of primary care specifically for low-income seniors and their primary care physicians (PCPs) to improve the quality of geriatric care to optimize health and functional status, decrease excess healthcare use, and prevent long-term nursing home placement. The GRACE model of intervention is still in the evaluation phase, but the hypothesis is that patients enrolled in the GRACE program will have better health status, greater functional independence, fewer emergency department visits and hospitalizations, and fewer nursing home days over two years of follow-up than patients receiving usual care.
Clinical Practice Change: Group Visits Group visits are a new model of care that recognize the discordance between the expanding needs of older adult patients with chronic illness and the acute-care orientation of the typical 15-minute office visit. The main goal of the group visit is to facilitate self-management of self care, peer and professional support, and attention to the psychosocial aspects of living with chronic illness. (Coleman et al., 2001)
Group Visits in New Orleans Senior High Rise Building One group visit per month with 5 seniors (ages 66-82, 1 Hispanic, 4 Black, 3 females, 2 male, all with several comorbidities such as HTN, DM, COPD, and CAD). So far, only two group visits have been made. Providers involved: NP, Podiatrist, Optometrist, RN, and Social Worker Visits begin with meet-n-greet and then a brief presentation on the topic of the month is given. The medical assistant takes vitals and administers shots while the other providers perform their respective duties. Time is allowed for one-on-one consultations with the PCP. Healthy refreshments are usually offered after each session. Total session time has been approximately 60 minutes.
Evaluation Plan Evaluation sheets were administered after the second group visit. The patients were asked to indicate where improvements could be made and what additional services were needed. So far, the group visits have been a huge success. Many new residents want to attend and several have asked for dental services and additional information on available community resources such as: Road Home information and transportation assistance.
Future Plans The future plans are to find a dentist or solicit information from the LSU Dental School about possible dental students to give exams or teeth extractions. Offer group visits at other senior homes in different neighborhoods. Research possible grant options to assist with the acquisition of electronic medical record. Consider offering diagnostic capabilities such as: x-ray, EKG, and ultrasound options.
Proposed Journals for Submission Journal of the American Academy of Nurse Practitioners Geriatric Nursing Journal of Advanced Nursing Journal of Nursing Administration Journal of Professional Nursing
Bibliography Chumbler, N. R., Vogel, W. B., Garel, M., Qin, H., Kobb, R., & Ryan, P. (2005). Health Services Utilization of a Care Coordination/Home-Telehealth Program for Veterans With Diabetes: A Matched-cohort Study. Journal of Ambulatory Care Management, 28(3), 230-240. Coleman, E. A., Eilersten, T. B., Kramer, A. M., Magid, D. J., Beck, A., & Conner, D. (2001, March/April). Reducing Emergency Visits in Older Adults with Chronic Illness: A Randomized, Controlled Trial of Group Visits. Elective Clinical Practice, 4(2), 49-57. Counsell, S. R., Callahan, C. M., Buttar, A. B., Clark, D. O., & Frank, K. I. (2006, July). Geriatric Resources for Assessment and Care of Elders (GRACE): A New Model of Primary Care for Low-Income Seniors. Journal of the American Geriatrics Society, 54(7), 1136-1141. Dorr, D. A., Wilcox, A., Burns, L., Brunker, C. P., Narus, S. P., & Clayton, P. D. (2006). Implementing a Multidisease Chronic Care Model in Primary Care Using People and Technology. Disease Management, 9(1), 1-15. Hendrix, C. C., & Wojciechowski, C. W. (2005, July). Chronic Care Management for the Elderly: An Opportunity for Gerontological Nurse Practitioners. Journal of the American Academy of Nurse Practitioners, 17(7), 263-267. Kobb, R., Hoffmann, N., Lodge, R., & Kline, S. (2003). Enhancing Elder Chronic Care through Technology and Care Coordination: Report from a Pilot. Telemedicine Journal and ehealth, 9(2), 189-195. Leveille, S. G., Wagner, E. H., Davis, C., Grothaus, L., Wallace, J., & LoGerfo, M. et al. (1998, October). Preventing Disability and Managing Chronic Illness in Frail Older Adults: A Randomized Trial of a Community-Based Partnership with Primary Care. Journal of American Geriatrics Society, 46(10), 1191-1198. Stille, C. J., Jerant, A., Bell, D., Meltzer, D., & Elmore, J. G. (2005, April 19). Coordinating Care across Diseases, Settings, and Clinicians: A Key Role for the Generalist in Practice. Annals of Internal Medicine, 142(8), 700-709.