OUR HEALTHCARE SYSTEM has several neighborhood primary care clinics that serve a diverse population of uninsured or underserved patients. Currently, the clinics are in transition as they prepare to become patient-centered medical homes (PCMHS). PCHM is a model of primary care delivery that focuses on individualized care. It seeks to improve patient outcomes by involving patients in creating a care plan based on the individual patient and family needs.1 This transition is based on the 2008 National Commission on Quality Assurance (NCQA) PCMH model, which seeks to improve patient outcomes at the primary care level.1 Through its established best-practice standards, the 2008 model challenges primary care practices to provide, coordinate, and sustain holistic, patient-centered care to meet patient and family needs.2
As PCMHs become more common, nurses are assuming more responsibilities as members of the care team. This article discusses the use of an evidence-based algorithm to guide and standardize nursing interventions for the care management of patients with type 2 diabetes mellitus (T2DM).
Care management and care coordination are central to the success of a PCMH. The 2008 standards and guidelines stipulate that nonphysician staff, such as nurses and social workers, must share the responsibility of care management and coordination.2
As a subset of its standards, the NCQA requires participating primary care clinics to identify three chronic medical conditions for which the clinic provides care management and self-management support to patients to improve and sustain positive patient outcomes. Using a special matrix based on the International Classification of Diseases (ICD-9) codes, the medical quality coordinator of our health system identified hypertension, obesity, and T2DM as priority conditions for management. Care management of patients with hypertension or obesity is beyond the scope of this article.
Diabetes is the leading cause of acute kidney injury, nontraumatic lower limb amputations, and new cases of blindness among adults in the United States.3 It's also one of the major causes of heart disease and stroke.3 Managing or coordinating the care of patients with diabetes is a primary care responsibility, yet despite the wide range of pharmacologic treatments and multiple programs available to improve diabetes care, data from the CDC reveal that disease control remains suboptimal.4
Studies have shown that nurse-led diabetes care management is an effective strategy for improving diabetes care and patient outcomes.5 Care management is a structured, evidence-based program that engages patients and family members to collaborate in goal setting and problem solving to manage their health conditions.5 The goal is for the care manager—a nurse—to work with patients and healthcare providers to coordinate care and develop planned activities that will ultimately optimize patient wellness and functioning. This involves identifying community resources and services that can help improve disease management and outcomes. Care management shifts the care of patients from episodic to ongoing so caregivers can address potential complications before they occur or worsen.
When executed appropriately, care management offers customized patient education and coaching that nurses can use to guide patients to formulate an individualized plan. By letting patients make choices, this approach supports improved self-care and plan adherence.
The conceptual framework of the algorithm we created is grounded in Orem's nursing theory of self-care.6 Orem postulates that it's up to nurses to guide patients and their families toward providing their own care according to their individual functional level, sociocultural life experiences, and available resources.6
Before the creation of the algorithm, we conducted a literature review. We selected research that demonstrated best practices and evidence-based protocols and guidelines for nurse-led interventions proven to have had a positive impact on care management of patients with T2DM. A compilation of interventions gleaned from the literature, coupled with the health system's existing diabetes standing orders, were formulated into an algorithm to guide nursing actions. (See T2DM algorithm of care.)
An educational curriculum is being developed for nurses who'll fill the role of care managers. Nurses will be trained to use the algorithm and will also learn motivational interviewing, effective goal setting, caregiver support, and community resource utilization. Motivational interviewing is an evidence-based method of questioning that's used to counsel patients with substance abuse problems. The open-ended, person-centered questions help patients to identify barriers that must be overcome to change their behavior.7 Upon successful completion of the training, the algorithm will be implemented systemwide.
The algorithm is designed for the care of patients with a history of uncontrolled T2DM. The inclusion criteria are as follows: patients must have an established primary care provider (PCP) within the healthcare system and have been identified by their providers as potential beneficiaries of care management.
Once a patient with T2DM is identified for care management, the PCP flags the patient's medical record, indicates the reason for care management, and hands the case to the nurse care manager. The nurse uses the algorithm to proceed with individualized care. He or she calls the patient to begin the care management process. The conversation starts with an introduction of the care manager and the purpose of the phone call. If a patient declines care management, the care manager documents the patient's decision in the medical record, encourages the patient to keep follow-up appointments, informs the patient's PCP, and then closes the case.
Patients who agree to care management are assessed by the care manager for greatest needs and risk factors and are prioritized according to acuity or deficit level. In the case of an immediate medical need, the care manager triages the patient according to established clinic protocols, and directs him or her to seek care at the nearest ED or during a same-day clinic visit.
If the patient doesn't have acute needs, the care manager proceeds with a general phone assessment and categorizes the patient as “deficit,” indicating the patient needs self-management support. If indicated, the care manager sets up a time for the patient to come in for a physical assessment. Based on our clinic's standing orders, the care manager can perform monofilament testing, administer indicated immunizations, and obtain specimens for lipid profile, hemoglobin A1C, and microalbumin urine tests. Patients with abnormal results or who don't meet target values will be referred back to their PCP for follow-up.
A patient may need support for self-managing medication, diet, physical activity, weight, and/or BP. If this is the case, the care manager uses motivational interviewing techniques, assesses the patient's readiness to participate in his or her own care, and identifies barriers that might interfere with goal attainment.
After these patient assessments, while providing education and coaching, the care manager helps the patient create a plan of care that the patient believes can be achieved. The care manager reviews the plan and goals with the patient, and the patient agrees on a date for follow-up contact.
Generally, follow-up calls are made 2 weeks after the initial contact and then monthly. The purpose of follow-up calls is to assess progress, provide support, and identify barriers that impede goal fulfillment and adherence to the care plan. If the patient is making progress or has attained the planned goal, the care manager compliments the patient, reinforces the outcome, and engages the patient in setting new goals. If the patient declines continued care management, the care manager reaffirms the patient's achievement and encourages him or her to sustain the goal. The care manager discusses the patient's outcomes and decision with the PCP and closes the case.
If a follow-up phone call reveals that the patient has abandoned the care plan, is struggling to adhere to it, and has failed to achieve goals, the care manager uses motivational interviewing techniques to assess goal barriers, leads the patient in problem solving, and explores new options or refocuses on the planned goals. Follow-up calls in these cases are conducted bimonthly until the patient reports progress toward goal fulfillment.
The care manager documents every encounter with the patient and includes identified barriers, recommended resolutions, and outcomes. Ongoing collaboration takes place between the care manager and the patient's PCP to inform and assess any outcomes of the interventions.
The evidence-based algorithm is a helpful resource in promoting nurses' competence and confidence levels. Care managers can be interviewed before using the algorithm and at 3- or 6-month intervals to gain their perspectives on the usefulness of the algorithm. A patient's status can be reviewed during the same timeframe. Baseline diagnostic studies and diet adherence can then be compared to map patient outcomes. Later on, other variables such as medication adherence can be added to use as measures of program effectiveness.
Further work can be done to examine data from the electronic medical record system to compare patients who've received care management using the algorithm with those who refused care management. A comparative study can be conducted to determine any downward trending in the volume of ED visits and unplanned clinic visits related to the implementation of the algorithm.
Empowering nurses, patients
The delivery of care in the PCMH is greatly impacted by the involvement of nursing staff. Using the care management algorithm empowers nurses, as care managers, to offer evidence-based interventions to improve patient care. This role further validates the nursing staff and creates an opportunity for nurses to optimize their education and scope of practice.