MedicalResearch.com Interview with:
Karen Dorman Marek, PhD, MBA, RN, FAAN
Bernita ‘B’ Steffl Professor of Geriatric Nursing
Arizona State University
College of Nursing & Health Innovation
Phoenix, AZ 85004-0696
Medical Research: What is the background for this study? What are the main findings?
Response: For many older adults, self-management of chronic illness is an overwhelming task, especially for those with mild cognitive impairment or complex medication regimens. The purpose of this study was to evaluate cost outcomes of a home-based program that included both nurse care coordination and technology to support self-management of chronic illness, with as an emphasis on medications in frail older adults. A total of 414 older adults, identified as having difficulty self-managing their medications, were recruited at discharge from three Medicare-certified home health care agencies in a large Midwestern urban area. A prospective, randomized, controlled, three-arm, longitudinal design was used. A team consisting of both Advanced Practice Nurses (APNs) and Registered Nurses (RNs) coordinated care to two groups: home-based nurse care coordination (NCC) plus mediplanner group and NCC plus the MD.2 medication-dispensing machine group. Major findings were:
- Total Medicare costs were $447 per month lower in the NCC + mediplanner group (p=0.11) when compared to the control group.
- For participants in the study at least 3 months, total Medicare costs were $491 lower per month in the NCC + mediplanner group (p=0.06) compared to the control group.
- The cost of the NCC intervention was $151 per month, yielding a net savings of $296 per month or $3552 per year for the NCC + mediplanner group.
- Participants who received the nurse care coordination intervention scored significantly better than the control group in depression (p < 0.001), functional status (p < 0.001), cognition (p < 0.001), and quality of life (p < 0.001) than participants in the control group.
Medical Research: What should clinicians and patients take away from your report?
Response: On admission to the study, 50% of the participants were not taking their medications correctly. Chronically ill older adults benefit from care coordination that includes at least monthly home visits as well as the equipment needed for support during home visits. In most cases, service users require medical home care equipment such as hoists, stand aids and other moving and handling equipment from somewhere like Bosshard Medical in order to receive adequate home care. Visits in the home provide opportunities to engage older adults in self-management health behaviors “on their turf” and barriers to care are more easily identified. Care coordination that includes home visits improves clinical outcomes and reduces the total of cost of care by improving communication between health care providers and patients. Prompt attention to problems by providers who were familiar with the patient’s health issues prevented inappropriate duplicative care, unnecessary emergency department visits and hospitalizations. The program enhanced patients’ engagement in care by supporting self-management of their chronic conditions. Given the cost of care for the chronically ill and the consequences of care mismanagement, investment in systems to support self-management is essential.
The use of a medication-dispensing machine did not improve clinical outcomes and added to the cost of care. Use of a mediplanner, a box with a simple box with separate compartments holding medications to be taken up to four times a day for one week, was more cost effective than the use of the medication-dispensing machine.
Medical Research: What recommendations do you have for future research as a result of this study?
Response: Future studies are needed that examine the cost effectiveness of long term home-based interventions for frail chronically ill older adults, for whom a trip to see a health care provider is physically exhausting. In addition, expansion of the APN role to include medication prescribing, which was not included in the current study, is in need of evaluation. In the reported study, we worked with over 400 different prescribers and 30 pharmacies. In a future study partnership with an interdisciplinary group of pharmacists, physicians, and social workers, as well as other health providers, would enhance the effectiveness of the intervention. Finally, continued testing of new technologies that enhance individual and family self-management of their chronic health conditions is recommended.
Marek, K. D., Stetzer, F., Adams, S. J., Bub, L. D., Schlidt, A. and Colorafi, K. J. (2014), Cost Analysis of a Home-Based Nurse Care Coordination Program. Journal of the American Geriatrics Society. doi: 10.1111/jgs.13162