Chronic Disease

Management in the
Older Adult

ROSA D. DEVERA, PhD, RN

 What is Chronic Disease Management?

A “comprehensive, integrated approach to the care

and reimbursement of high cost chronic illnesses”
through management and treatment of the disease.

(Marquis and Huston, 2012)

 Goal of Chronic Disease Management
The main goal of chronic disease management is to address
chronic disease in an economically efficient and integrated
manner that provides the best patient outcomes.

Cost of Chronic Disease Management

Over 2 trillion is spent in the United States annually.
95% of this is direct patient medical care for older adults.

(Kapustin, 2010)
 Is Chronic Disease Management
Relevant to Older Adults?

YES !!!

80% of older adults have at least one

chronic disease that they are trying to
manage at home either alone or with the
assistance of family members.

(Healthy
 My Intention
Chronic disease management interests me
Education and
because I’ve seen thru my own nursing patient self-
practice that patients and families want
help managing their chronic illnesses. empowerment
There is a real desire from them to want to
are the keys to
learn more.
chronic disease
My intention is to help clinicians learn management.
how to help patients manage their
chronic illnesses more efficiently,
effectively and achieve better outcomes.
 Support Techniques
Chronic Disease and
 Assessment
Self-Management
 Build Rapport
 Empower Patient
Self-management support is “the systematic
 Problem Solving
provision of education and supportive
interventions to increase patients’ skills and  Identify Barriers
confidence in managing their health  Collaboration
problems, including regular assessment of  Effective Listening
progress and problems, goal setting and  Set goals
problem solving support.”
 Evaluation

(Clark et al., 2009)

 Chronic Disease Steps of the
Management and the Nursing Process
Nursing Process
 Assessment
Clinicians can use each step of the  Diagnosis
nursing process when utilizing the  Outcomes / Planning
support techniques of patient self-  Implementation
management.
Evaluat ion

(ANA, 2014)
 Application using the
Nursing Process Assessment
 Complete a comprehensive A systematic,
assessment and history dynamic way
to collect and
 Assess the chronic illness analyze data
 Assess patient’s willingness about a client,
the first step
to change lifestyle behaviors in delivering
 Assess patient’s level of nursing care.

health literacy

(ANA, 2014)
 Application using the
Nursing Process Diagnosis
 Knowledge Deficit The nurse’s
clinical
 Ineffective self-health management judgment about
the client’s
 Readiness for enhanced self-health response to
actual or
management potential health
conditions or
 Readiness for enhanced knowledge
needs.
 Risk for situational low self-esteem

(ANA, 2014)
 Application using the
Nursing Process Outcomes /
Planning
 Develop SMART goals
 Specific The nurse sets
measurable and
 Measureable
achievable
 Achievable short- and
long-range
 Relevant
goals.
 Timing

(ANA, 2014)
 SMART Goals
 should be related to their chronic disease
 aimed at helping the patient understand the connection between
disease management, and their behaviors
 avoid over ambitious goals
 should target a specific behavior

Example of a SMART Goal for Diabetic Patient:

I will check my blood sugar each morning before breakfast

and record the results daily for the next 7 days.

(Chronic Care and Disease Management, 2010)

(Suter, Hennessey, Harrison, et al., 2008)
 Application using the
Nursing Process

 Promote change through Care is

implemented
behavior modification according to the
 Follow SMART Goals care plan and
documented in
 Keep logs the patient’s
 Be the patient coach record.

 Teach about chronic illness

(ANA, 2014)
Application using the
Nursing Process Evaluation

 Evaluate logs and status and the

effectiveness of
journals
the nursing care
 Evaluate SMART goal must be
continuously
attainability
evaluated, and
 Adjust SMART goals the care plan
modified as
where needed
needed.

(ANA, 2014)
 Evidenced Based Practice
Sutter Care Coordination Program
Sutter Health Sacramento-Sierra Region
 Used chronic care and disease management teams of
RN’s and Medical Social Workers

 38 percent fewer home health care visits

 Reduced emergency department visits by 13 percent
 Reduced hospitalizations by 39 percent

 Increased patient and caregiver understanding of chronic

disease and symptom management by using self-
management techniques including education, lifestyle
modification and goals.
(Chronic Care and Disease Management, 2010)
 Evidenced Based Practice
Self-Management Among
Socioeconomically Vulnerable Older
Adults
 23 older adults below 200% poverty level & no insurance
 12 older adults with private health insurance.

 vulnerable sample had lower educational attainment &

lower
health literacy
 privately insured group expressed health promotion as the key to
healthy aging and had awareness of self-management leading to
improved chronic care outcomes
 The vulnerable interviewees did not have expectations for
healthy aging.
 Evidenced Based Practice
The Development of a Community and Home-based
Chronic Care Management Program for Older
Adults.
Objective: To evaluate a chronic care management program piloted by a
visiting nurses association

 Provided educational development for nurses

 Piloted encounters with patients with chronic conditions
 Chronic care professional modules were used to increase nurses'
knowledge—verified with exam

 Patient improvement in self-management and clinical measures

 Nurses were prepared to provide effective encounters to improve self-
efficacy and clinical outcomes for older adults with chronic conditions.
(Cooper, 2013)
 Solutions for Clinicians
Patient
How to Help Your Patient Manage
confidence
Chronic Disease
yields
 Use the Nursing Process Interventions
improved
outcomes
 Understand the Disease itself
through a
 Promote Self-Management
more suitable
 Reconcile Medications patient
 Care Coordination: PT, OT, and ST decision
 Increase Visits During Early Phase of New Disease making
 Relate behavior changes to positive outcomes
process.
 Establish Meaningful Relationship

(Suter, Hennessey, Harrison, et al., 2008)

 Discussion Scenario
You are currently a home health nurse visiting with a newly diagnosed
diabetic patient. This is your first visit with the patient and you are
unsure what she already knows about diabetes. The patient lives with
her daughter who is a very busy single mom. Many nights, dinner
consists of fast-food meals or microwave dinners. The patient drinks
sodas during the day, but states that she drinks only water at night. She
checks her blood sugar “when she feels funny” and “she never keeps a
log.”
Using the nursing process, what are some initial interventions that
you can perform to determine the patient’s level of understanding
regarding diabetes management? How can you assist her in setting
SMART goals? What SMART goals would you establish initially?
 References
ANA. (2014). The Nursing Process. Retrieved March 19, 2014, from http://
www.nursingworld.org/EspeciallyForYou/What-is-Nursing/Tools- You-
Need/Thenursingprocess.html

Chronic Care and Disease Management | AHRQ Innovations

Exchange. (2010). Pennsylvania Homecare Association

Chronic Care and Disease Management. Retrieved February 20,

2014, from http://www.innovations.ahrq.gov/content.aspx?id=1696

Clark, D., Frankel, R., Morgan, D., Ricketts, G., Bair, M., Nyland, K., &
Callahan, C. (2009). The meaning and significance of self-
management among socioeconomically vulnerable older
adults. Journals Of Gerontology Series B: Psychological Sciences
& Social Sciences, 63B(5), S312-9.
 References
Cooper, J., & McCarter, K. (2013). Result Filters. National Center for
Biotechnology Information. Retrieved March 22, 2014, from http://
www.ncbi.nlm.nih.gov/pubmed/24387773

Healthy Aging. (2011). Centers for Disease Control and Prevention.

Retrieved March 16, 2014, from
http://www.cdc.gov/chronicdisease/resources/publications/aag/
aging.htm

Kapustin, J. (2010). Chronic Disease Prevention Across the Lifespan. The

Journal for Clinician Practitioners, 6(1), 16-24.

Marquis, B.L., & Huston, C.J. (2012). Leadership roles and management
functions in nursing: Theory & application (7th ed.).
Philadelphia: Lippincott.
 References
Suter, P., Hennessey, B., Harrison, G., Fagan, M., Norman, B., & Suter, W.
(2008). Home-based chronic care. An expanded integrative model for home
health professionals.. Home Healthcare Nurse, 4(26), 222-9