DM and Chronic Care
Nurse-driven model gains elder lifestyle changes
The Cardiovascular Disease (CVD) Initiative serves primarily elders, but few older than 75. "There’s uncertainty as to how aggressively [patients age 76-plus] should be treated for cholesterol management," explains internist Anthony Woolley, MD, with HealthSystem Minnesota, a Minneapolis-based ambulatory care group. He sees the program as a good model for serving large numbers of people with chronic conditions. "We can get closer to the goal levels of blood pressure and cholesterol management and smoking cessation."
For managed care patients, he observes, seeing people less often is a good thing, but the CVD Initiative achieves remarkable results by seeing them more often. "We pay close attention to their conditions until they reach goal levels," says cardiovascular disease prevention services manager Linda Leimer, RN. "After that, we schedule their visits and call to remind them of their appointments. We don’t just say come back and see us in six months’ and leave it to them." Eighteen months into the program, 14% of the smokers had stopped for over six months. "That’s way over the national average," Leimer observes. (For additional outcomes of the CVD Initiative, see the box "CVD Initiative — pilot site," p. 18.)
Several other features distinguish the CVD Initiative from traditional acute care models:
• Delivery revolves around the nurse. "The nurses live in the primary care clinics, and they coordinate patient care with the specialists." While patients visit specialists as needed, their home base is the primary care clinic.
• The focal point of service delivery for patients with multiple conditions is the one requiring most rigorous management. For example, a person whose diabetes is out of control might visit the CVD Initiative programs once or twice but would remain in the diabetes program for ongoing care.
• Information systems address many of the communication needs. The electronic medical record (EMR) now encompasses all the documentation. Nurses write their notes by hand and later transcribe them to the EMR. However, that will change, Leimer notes. Soon, nurses will chart directly on the EMR.
Improvements in progress
1. Provider fact sheets will list clinic and community resources for chronic disease patients.
2. A visit planning process will help providers coordinate appointments for their chronic disease patients. For example, if a patient comes in for a hypertension appointment, she might also get a mammogram and have her feet checked for signs of diabetes-related circulatory problems.
Standard reimbursement creates problems
While this model produces enviable results in health outcomes and patient satisfaction, it struggles to break even. "Medicare and managed care companies don’t reimburse on outcomes or how well we control risk factors," Woolley notes. "In our system, the nurses might spend a half-hour educating patients when they need it, and the doctor might spend two minutes on a checkup. But reimbursement for the doctor is greater," he continues. "We’ve improved access to care by replacing doctor visits with nurse visits, but we can hardly make ends meet." That challenge remains to be solved.
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