CNS-directed case management. Cost and quality in harmony

Translation and validation of the Greek version of the Jefferson Scale of Attitudes toward Physician and Nurse Collaboration (JSAPNC)

The Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration (JSATPNC) is an established tool to assess attitudes toward physician-nurse collaboration. The aim of this study was to translate and culturally adapt the JSATPNC for use in Greece and test its psychometric properties. The final study sample included 621 physicians and nurses working in two general hospitals of Northern Greece during 2017. The study sample was randomly split into two halves; separate exploratory and confirmatory factor analyses were conducted. A regression analysis including sociodemographic variables was performed to predict the JSATPNC total score. The Cronbach's alpha was .74. A four-scale model (a) interprofessional collaboration, (b) involvement in decision-making, (c) expertise, (d) physician's dominance was extracted from the exploratory factor analysis. The confirmatory factor analysis indicated an acceptable model fit (RMSEA = .069, SRMR = .083, TLI = .875, CFI = .903). There was adequate evidence for both convergent and discriminant validity, apart from the "physician's dominance" scale; the exclusion of items 9 and 12 from this scale resulted in an alternative model with the improved model fit (RMSEA = .062, SRMR = .078, TLI = .902, CFI = .916). The test-retest intraclass correlation coefficients were all above .7. Age and profession of the respondents emerged as important predictors of the total scale score. The Greek version of the JSATPNC shows promise as a reliable and valid instrument for evaluating collaboration between physicians and nurses.

The Assessment of Services Promoting Independence and Recovery in Elders Trial (ASPIRE): a pre-planned meta-analysis of three independent randomised controlled trial evaluations of ageing in place initiatives in New Zealand

INTRODUCTION

intermediate care has been developed to support older people to remain living in their own homes, combining a higher level of support with a rehabilitation focus. Evidence around their effectiveness remains mixed and there is ambiguity around the components.

AIMS

to establish the impact of intermediate care on institutional free survival in frail older people referred for needs assessment in New Zealand (NZ).

METHODS

pre-planned meta-analysis of three randomised controlled trials with follow-up at 3, 6, 12, 18 and 24 months. A total of 567 older people at risk of permanent institutionalisation as well as their primary informal carer (n = 234) were randomised to either intermediate or usual care. Interventions had common key features of care management, though varied in the use of ongoing care provision.

RESULTS

the adjusted hazard ratio for the combined primary outcome of death or residential entry was 31% lower with a 95% confidence interval of (9%, 47%) for the intermediate care initiatives compared with usual care.

CONCLUSION

intermediate care utilising a care management approach reduces a frail older person's risk of mortality and permanent institutionalisation.

Should care managers for older adults be located in primary care? A randomized controlled trial

OBJECTIVES

To determine the effect of a primary care-based care management initiative on residential care placement and death in a population of frail older adults referred for needs assessment in New Zealand.

DESIGN

Randomized controlled trial with follow-up at 3, 6, 12, 18, and 24 months for residential care placement and mortality.

SETTING

Fifty-five family physician practices in New Zealand that established a care management initiative for older adults assessed as being at high risk of residential care placement in 2004 to 2006.

PARTICIPANTS

Three hundred fifty-one individuals (243 female, 108 male) aged 65 and older (mean 81) who were assessed as being at risk of permanent residential care placement.

INTERVENTIONS

The care management program (Coordinator of Services for Elderly) consisted of a nominated health professional care manager geographically aligned to family physicians housed with the family physician or located nearby.

MEASUREMENTS

Rates of permanent residential care placement and mortality.

RESULTS

The risk of permanent residential care placement or death was 0.36 for usual care (control group) and 0.26 for the care management initiative, a 10.2% absolute risk reduction, with the majority of the risk reduction seen in residential care placement (control group 0.25, intervention group 0.16).

CONCLUSION

A family physician-aligned community care management approach reduces frail older adults' risk of mortality and permanent residential care placement.

Intensive care medicine trainees' perception of professionalism: a qualitative study

The Competency-Based Training program in Intensive Care Medicine in Europe identified 12 competency domains. Professionalism was given a prominence equal to technical ability. However, little information pertaining to fellows' views on professionalism is available. A nationwide qualitative study was performed. The moderator asked participants to clarify the terms professionalism and professional behaviour, and to explore the questions "How do you learn the mentioned aspects?" and "What ways of learning do you find useful or superfluous?". Qualitative data analysis software (MAXQDA2007) facilitated analysis using an inductive coding approach. Thirty-five fellows across eight groups participated. The themes most frequently addressed were communication, keeping distance and boundaries, medical knowledge and expertise, respect, teamwork, leadership and organisation and management. Medical knowledge, expertise and technical skills seem to become more tacit when training progresses. Topics can be categorised into themes of workplace-based learning, by gathering practical experience, by following examples and receiving feedback on action, including learning from own and others' mistakes. Formal teaching courses (e.g. communication) and scheduled sessions addressing professionalism aspects were also valued. The emerging themes considered most relevant for intensivists were adequate communication skills and keeping boundaries with patients and relatives. Professionalism is mainly learned 'on the job' from role models in the intensive care unit. Formal teaching courses and sessions addressing professionalism aspects were nevertheless valued, and learning from own and others' mistakes was considered especially useful. Self-reflection as a starting point for learning professionalism was stressed.

A meta-analysis of the effect of hospital-based case management on hospital length-of-stay and readmission

BACKGROUND

Although many hospital-based case management (CM) interventions have been studied, there is little work summarizing the effectiveness of these studies.

OBJECTIVES

The purpose of this study was to investigate the effect of hospital-based CM compared with usual care on length of hospital stay and readmission rate.

METHOD

A meta-analytic method was employed to analyze the effect sizes of CM intervention on outcomes. Eligible studies were retrieved using computerized database searches, footnote chasing, and contact with content experts. The authors reviewed the final 12 studies, and the effect size, 95% confidence interval (CI), sensitivity, homogeneity, and publication bias were analyzed.

RESULTS

The overall average weighted effect size on length of stay (LOS) was 0.094 with a 95% CI of -0.032 to 0.220. The overall odds ratio for readmission was 0.87 with a 95% CI of 0.69 to 1.04. Overall, hospital-based CM interventions were not significantly effective in reducing LOS and readmissions. However, CM for patients with heart failure (effect size of 0.241 with a 95% CI of 0.012 to 0.470) was significantly effective in reducing LOS, although it was not effective for stroke patients (effect size of -0.226 with a 95% CI of -0.542 to 0.089) and frail elders (effect size of 0.126 with a 95% CI of -0.073 to 0.324). Analysis indicated that in this meta-analysis publication bias was unlikely.

DISCUSSION

The findings of this meta-analysis demonstrate a 6% decrease in readmission rate for patients who received hospital-based CM interventions. Further meta-analytic studies are needed to investigate the effectiveness of CM on other outcomes.

Physician–nurse attitudes toward collaboration in Istanbul's public hospitals

The need for greater collaboration between nurses and physicians in clinical practice is essential to improve patient care and worker satisfaction. This study used t-tests and logistic regression to test four research hypotheses concerning attitudes toward physician-nurse collaboration in Istanbul, Turkey. The study found that nurses express more positive attitudes toward collaboration than physicians. Noteworthy was the finding that male physicians expressed more positive attitudes toward collaboration than female physicians. Residents and those employed in secondary institutions were also more likely to express more positive attitudes toward collaboration than permanent physicians and those employed in tertiary hospitals.

Nursing Telephonic Case Management and Pregnancy Outcomes of Mothers and Infants

Limited success has been achieved in identifying high-risk pregnant women via prenatal risk identification tools. The purposes of this study were to examine a risk assessment and nursing telephonic case management protocol used to identify high-risk mothers and infants, and to evaluate the costs and benefits of the protocol. This study involved a retrospective review of insurance data held by a large managed care organization (MCO). Analyzed data included information about current and past medical problems, and current lifestyle risk factors. Data analysis included frequencies, chi2, t tests, and logistic regression analysis. Pregnant MCO members experienced fewer high-risk conditions versus nonmembers. The overall pregnancy cost for a member was 1,818 dollars versus 4,587 dollars for a nonmember. Members experienced 2.5 times fewer babies hospitalized in the NICU, and significantly fewer mothers with high-risk conditions. The MCO program reduces costs and promotes better maternal and infant outcomes.

Comparisons of American, Israeli, Italian and Mexican physicians and nurses on the total and factor scores of the Jefferson scale of attitudes toward physician-nurse collaborative relationships

This cross-cultural study was designed to compare the attitudes of physicians and nurses toward physician-nurse collaboration in the United States, Israel, Italy and Mexico. Total participants were 2522 physicians and nurses who completed the Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration (15 Likert-type items, (Hojat et al., Evaluation and the Health Professions 22 (1999a) 208; Nursing Research 50 (2001) 123). They were compared on the total scores and four factors of the Jefferson Scale (shared education and team work, caring as opposed to curing, nurses, autonomy, physicians' dominance). Results showed inter- and intra-cultural similarities and differences among the study groups providing support for the social role theory (Hardy and Conway, Role Theory: Perspectives for Health Professionals, Appelton-Century-Crofts, New York, 1978) and the principle of least interest (Waller and Hill, The Family: A Dynamic Interpretation, Dryden, New York, 1951) in inter-professional relationships. Implications for promoting physician-nurse education and inter-professional collaboration are discussed.

New perspectives on advanced practice nursing case management for aging patients

Providing case management for older individuals is challenging in that this group rarely fits any DRG or managed-care mold. Because many people are living healthier and longer lives, intergenerational family dynamics such as that observed in Sophie and Leo's case may become more the norm than the exception. Well-intentioned family members, lacking the guidance of an experienced gerontologic APN case manager, may inadvertently place their aged loved ones at risk by attempting to arrive at health care, social, and housing solutions on their own. Even though 82-year-old Sophie stated subjectively that she "felt better than ever", an objective clinical assessment revealed that she still was in a convalescent period following major abdominal surgery at the same time that she was faced with providing in-home care for Leo, her 102-year old father. Sophie may have experienced response shift, or a reconceptualization of her own health state, in the aftermath of serious illness. The advanced practice knowledge and skills, systems acumen, talents, and creativity of two APN case managers in two different states contributed to successful health and social outcomes for two "master survivors," whose longevity and clinical presentations exceeded expectations. The value of APNs as case managers is clear: APNs possess the proficiency, tenacity, knowledge base, and nursing confidence needed to make a positive contribution toward individualizing care for members of the greatest generation.

Case management: evolution of the concept in the 80's and 90's

Case Management is a term that is present in almost every American health care situation. It is mostly used to coordinate community services with satisfactory results for the patient within a certain period of time, with limited resources. Through time, it has been used for different purposes. The goal of this study was to show the historical evolution of case management as expressed by the American nursing literature, in the 80's and 90's, according to its use, meaning, and application, and following a theoretical framework for concept analysis. The data was extracted from two journals: "Nursing Management" and "Journal of Nursing Administration". The publications showed case management portrayed as a process that serves a common goal; where quality and cost of care were the prevalent and influential elements along time, and its practice focusing in a given population defined as of high risk and high cost for health care.

Long-term disease management needs of southern African Americans with diabetes

PURPOSE

This qualitative study explored the issues, concerns, and needs of low-income, southern African Americans in managing type 2 diabetes over time.

METHODS

Two focus groups (N = 22) were conducted with the target population to collect data. Group sessions were audiotaped and transcribed verbatim. Content analysis was used to analyze the data.

RESULTS

The data revealed an overall theme of learning to live with diabetes, which consisted of 3 processes: (1) symptom management, (2) making healthy choice, and (3) emotional adjustment. This article focuses on the processes of symptom management and making healthy choices. Findings suggest that the sequential processes of symptom management and making healthy choices occurred over time primarily through experiential learning in this population and were influenced by social support, caring and collaborative provider-client relationships, and access to resources and culturally sensitive supportive services.

CONCLUSIONS

Experiential educational methods that incorporate social support and access to resources may be more appropriate than the traditional didactic method of teaching diabetes self-care.

Nurse case managers in rural hospitals

Many rural hospitals are struggling to survive the capitated care environment by implementing nursing case management. However, little is known about what rural nurse case managers (NCMs) do to achieve outcomes or what their qualifications should be. This national survey of NCMs (N = 302) in rural hospitals suggests that individual advocacy, teaching, and clinical practice play key roles in the practice of rural NCMs and that the education and experience of NCMs does affect their practice.

The processes of case management: a review of the evaluation of a pilot study for elderly people in Hong Kong

AIM

This paper is based on research into case management that aimed to evaluate the processes of the introduction of case management for elderly people into the community nursing services in Hong Kong.

BACKGROUND

The Hospital Authority in Hong Kong introduced a pilot Case Management scheme into the Community Nursing Services. A research project was therefore developed to evaluate this case management model.

METHOD

The processes were measured through information gained from group interviews, daily diaries and weekly activity sheets.

FINDINGS

The roles and work practices of the Care Coordinators and Case Managers are described and the benefits of case management to patients, carers and nurses are highlighted. Difficulties are also discussed and good practices are identified.

CONCLUSION

Staff in the hospital and community need time to get used to the model of case management and to the accompanying documentation. The role of the case manager needs to be clearly dilineated.

Preparing Nurses for the Acute Care Case Manager Role: Educational Needs Identified by Existing Case Managers

BACKGROUND

There is little in the literature about how best to prepare nurses for case manager roles.

METHOD

Twenty acute care case managers were asked to identify skills and knowledge that would be of value to nurses new to case manager roles.

RESULTS

Community resources, discharge planning, and third party reimbursement were the top three educational needs identified by all case managers. Baccalaureate prepared case managers identified clinical issues to be of value, such as family coping, patient education, quality of life, and social support, while master's prepared nurses identified only system-related issues.

CONCLUSION

Educational programs preparing baccalaureate prepared case managers could focus on both clinical and system issues, while programs preparing master's educated case managers could focus primarily on managing system issues. Staff development professionals may also call on experts inside and outside the institution to assist in teaching about health care finance and reimbursement issues.

Case management: a review of the definitions and practices

Case management has been suggested as an innovative strategy which facilitates the linking of quality and cost-effective care. However, there is little consensus about what is actually being introduced under the name of case management. It is suggested that this absence of a clear understanding of case management has been an obstacle in moving forward case management practice and research. This paper presents a critical review of the confusion surrounding case management with an attempt to unravel issues relevant to the implementation of case management into community nursing practice in Hong Kong. It is concluded that there is a need for different definitions of case management as a result of the differences in the cultural and health care context in which it is being practised. Also, if case management programmes are to be advanced, there needs to be more co-ordinated effort in researching not only the expected outcomes but also the structures and processes of these programmes so that findings of similar case management programmes can be compared for ways of future improvement.

Case management programs in primary care

To review the impact of case management programs on health care resource use; their impact on patient satisfaction, quality of life, and functional status (patient-centered outcomes); and their cost-effectiveness, we reviewed the English language literature utilizing the following MEDLINE and HealthSTAR headings: case management, patient care planning, patient-centered care, disease management, care management, and managed care programs. Bibliographies of relevant articles were also reviewed. Only randomized controlled trials were included. Data were extracted manually from relevant publications and are presented descriptively because formal, quantitative methods were not applicable. Nine studies met our inclusion criteria. Of the seven studies examining case management's impact on health resource use, only two found a positive effect. Both successful programs targeted patients with specified disease conditions and care was supervised by a medical subspecialist. None of the programs targeting general disease conditions or supervised by generalists reported a positive effect. All six studies examining patient-centered outcomes reported a positive impact. These effects were unrelated to the patient's conditions or the study personnel. Both studies examining clinical parameters found a positive impact. Only three studies examined costs; all reported nonsignificant cost savings. While case management programs offer theoretical benefits, few examples of successful programs were found. Positive effect was related to disease condition and specialty training of study personnel. Patient-centered outcomes were often improved upon but at unknown cost. Further multisite clinical trials are needed to define case management's role in our future health care system.

The institution of care pathways in nephrology patient care: a response to the changing health care climate

The development of managed health care in the United States has provided an impetus for new strategies that promote efficiency, streamline healthcare delivery, and maintain quality care. The increasing number of end-stage renal disease patients, their complexity of care, and a looming manpower shortage in nephrology strain the present system trying to meet these demands. One mode of healthcare delivery that may address specific needs in the nephrology population is case management. This approach to medical care uses a care pathway that serves as a multidisciplinary blueprint for patient care. Such pathways eliminate duplicated services and maximize efficiency by keeping the healthcare team focused. In response to market forces in our community, we implemented care pathways for percutaneous renal biopsy and vascular access surgery. Costs per procedure and hospital length of stay were reduced. Patient outcomes and procedure success rates were unchanged from pre-pathway years. Moreover, patients preferred the care pathway care for their problems. Case management and care pathways are tools that are effective in their scope for helping deliver better care for nephrology patients. While they should not be considered a panacea for the problems facing renal care providers, these tools should be considered as part of nephrology healthcare delivery in the future.

Nursing case management and its role in perinatal risk reduction: development, implementation, and evaluation of a culturally competent model for African American women

The authors outline the need for comprehensive perinatal services management for African American pregnant women, based on social/environmental stressors, and propose a workable model for delivery of services based on case management principles. The implications of case management as an intervention to ameliorate these stressors are discussed. Data from 5 years of comprehensive case management are included to support the effectiveness of case management as an intervention among high-risk women. Steps utilized to develop, implement, and evaluate case management are also discussed.

The advanced practice nurse's role in differentiated practice: Martha's story

The changing health care environment and increasing patient acuity necessitate a coordinated effort among all health care disciplines to assure the best patient outcomes. The advanced practice nurse in the role of case manager is well qualified to serve as the leader of this team. Within the framework of differentiated practice, advanced practice nurses work in tandem with associate and primary nurses to ensure positive quality, financial, and satisfaction outcomes. Clinical expertise and knowledge of systems allow the advanced practice nurse to assist the patient through complex systems to achieve these ends.

Case management: a rich history of coordinating care to control costs

The process of case management has been used to coordinate health and human services in the United States for more than a century. Throughout its history, case management has been practiced by a variety of disciplines, primarily nursing and the social service disciplines. Regardless of the degree of sophistication of the case management model or the discipline practicing case management, historically the goal has been the same--coordination of complex, fragmented services to meet the needs of the client while controlling the costs of services. As the health care industry continues to evolve during the managed care era, case management seems to be pervading all health care delivery systems as a means of dealing with the issues of access and quality while containing costs. The long history of case management provides a strong foundation for the refinement of case management systems to meet the needs of clients in the 1990s.

Nursing care models increase care quality while reducing costs

Unique models of care delivery, such as the Nursing Care Partnership model for practice used at the Denver Nursing Project in Human Caring, have demonstrated a reduction in inpatient admissions, mean length of stay, and total charges. This descriptive study identified and described clients' (N = 75) perceptions of care and explored the cost-effectiveness of this model. Findings suggest nursing care partnerships play a key role in reducing healthcare costs by providing services in a more cost-efficient setting and by having an impact on client utilization of services. Savings in potential hospital costs were estimated at $1,590,384 for 1993.

The changing role of advanced practice nursing in a managed care environment

Advanced practice nursing in a managed care environment--is this an oxymoron? Can these two phrases exist together? Do advanced practice nurses have a role in a managed care environment? As health-care systems continue to merge and managed care impacts the bottom line, advanced practice nurses are challenged to show their worth. In this article, the author reviews the impact managed care has had on the roles of two master's-prepared traditional clinical nurse specialists. Included are examples of how the roles were adapted to fit in the managed care setting. The current role of the advanced practitioners is reviewed, using the common subroles as a basis for discussion. The impact of managed care on each component of the clinical nurse specialist role is identified. The author also demonstrates that advanced practice nurses can have a valuable role in the managed care environment.

Use of community resources by prenatal case managers

Comprehensive, community-based case management has been inadequately studied with regard to case managers' use of community resources. The purpose of the study was to identify what federal, state, and local health and social services are used by case managers in coordinating services for prenatal case management of high-risk, Medicaid-eligible women. Thirty-three case managers in two local health departments and one managed care organization provided three types of data about the community resources to which they refer clients. Categories of types of services were developed using content analysis. The results indicate that case managers refer their clients to 10 types of services. Federal assistance programs of Medicaid and the Women, Infant, and Children (WIC) nutrition program were used most. Hospitals, private physicians, family planning services, and transportation and housing services were frequently used. Implications for practice and research are discussed.