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Disease Management in diverse care settings

Sergey Makov

New York City College of Technology

Nursing Case Management

NUR 4030

Dr. Kathleen Falk

May 07, 2014

Disease Management in diverse care settings

The practice of Case Manager is constantly evolving. Certain factors may influence on the patient care, such as changes in health care laws, regulations, reimbursement concepts, and accreditations standards. In relation to all of influencing factors there is a need to manage the patients care. The practice of Case Manager is important because it provides support and ensuring that clients will receive an evidence-based care in different care settings (Tahan & Campagna, 2010, p. 245). Based on the data from the Agency for Healthcare Research and Quality (AHRQ) the adults with complex conditions and chronic illness are requiring professional help and monitoring throughout the progression of the illness. (Hickman et al., 2013, p. 2) In my paper I will describe the effectiveness of nursing case management of chronic conditions, such as congestive heart failure. Chronic diseases are the leading cause of illness, disability, and death in the U.S. Clients suffering from chronic illness is often requiring multiple resources, treatments, and providers. One of the proposals for improving care for chronic conditions is to develop programs that will improve care coordination and implement care plans. Nursing case management was proposed as one of the most effective services for coordinating and implementing a patient’s care plan, either alone or in conjunction with a team of health professionals (Hickman et al., 2013, p. 2). In my paper I will be focusing on the ways how nursing care management will improve the health and well being of clients with chronic condition such as congestive heart failure. The (4) main topics that will be discussed are: (a) coordinating of care; (b) clients teaching; (c) cost-effectiveness of nurse lead management of heart failure; (d) Case Manager and quality of life.

In order to manage the clients with CHF Nurse Case Manager implements many steps. The coordinating functions performed by a nurse case manager include helping patients navigate health care systems, connecting them with community resources and policies, managing of health care delivery (Hickman et al., 2013, p. 28). These coordinating functions are different from clinical functions because they including disease oriented assessment and monitoring, medication adjustment, health education, and self care instructions. In the context of chronic illness care, they are central to the role of a case manager as well, but a case manager also performs coordinating functions. The role of Nurse Case Manages in chronic illness care, and their distinction from other professionals involved in chronic illness management support, can be illustrated using the Chronic Care Model (Tahan & Campagna, 2010, p. 546). In order to improve clients outcome Nurse Case Manager implements productive interaction in the process of care. By using this techniques the client will stay informed and updated about his/her case and will be able prepared for any changes. Nurse Case Manager successfully communicates within interdisciplinary team in order to provide holistic care. Frequently clients with chronic conditions required multidisciplinary approach to disease treatment. Based on the current research successful interdisciplinary communication has a positive effect on client’s outcome (Hickman et al., 2013, p. 32). Nurse Case Manager Intervention for patients with congestive heart failure includes education, clinical monitoring for medication adjustment over the phone and home visits. Based on the Agency for Healthcare Research and Quality (AHRQ) the compliance rate for clients with CHF were higher compare to clients without phone or home monitoring (Hickman et al., 2013, p. 51). Based on the Disease Management Health Outcome research article researchers correlate certain Case Manager Intervention and it is positive effect on client’s health (Hebert & Sisk, 2008, p. 2). The following protocol-related nursing activities were the most effective in terms of it is beneficence. Nurse Case Mangers engaged in counseling services such as counseling about importance of medication adherence, restriction of dietary salt, restricting alcohol, and education on the appropriate actions to take if symptoms worsen. Research outcome data indicated on overall increase percentage of clients who give appropriate responses, such as call nurse, take medications when symptoms worsen , and overall decrease in number who give inappropriate responses, go to the emergency room, pray from survey question of what a patient does when symptoms worsen. (Hebert & Sisk, 2008, p. 2).

In addition to physical benefits financial benefits of Nursing Case Manger were identified as well. Based on American College of Physicians randomized controlled trials have shown that Nurse Case Manager leading disease management for patients with heart failure can reduce overall number of hospitalizations (Hebert et al., 2008, p. 1). Meta-analyses of randomized, controlled trials (RCTs) suggest that Nurse Case Management can be effective at reducing the rehospitalization rate for clients with CHF. Scientific studies establishing the cost-effectiveness of Nurse Manager Interventions for CHF may be especially important in minority communities, which have disproportionate rates of hospitalization for heart failure and showed the highest non compliant rate in the use of proven effective therapies and in patients’ understanding of heart failure (Hebert & Sisk, 2008, p. 540). By educating clients with CHF about community based clinics, educational program, and lifestyle modifications the overall rate of hospitalizations to acute settings hospitals were significantly decreased. (Hickman et al., 2013, p. 38).

In addition to physical and financial benefits the clients with CHF were assessed for the quality of life. Six studies examined the effect of CM on quality of life, using a variety of CHF specific assessment tools, including the Minnesota Living with Heart Failure Questionnaire,

The Kansas City Cardiomyopathy Questionnaire and the Chronic Heart Failure Questionnaire. Out of these six studies, three found significant improvements in CHF related quality among patients who were subjected to Case Manager care, one of which also found improvements in overall functional status (Hickman et al., 2013, p. 32). In the study showing improvements in overall functional status with Nurse Case Management , the improvement was observed in both physical and emotional domains of functioning. Clients engaged in care provided by Nurse Manager reported greater satisfaction with the treatment plan. Randomized controlled trials have shown that nurse led disease management for patients with heart failure can reduce hospitalizations.

The overall effectiveness of Nursing Case Management was supported by numerous researches. In order to test it is effectiveness for clinical practice researchers designed studies enrolling high risk patients. High risk was defined as having one or more risk factors for readmission. The Nurse Case Management showed it is effectiveness among ethnically diverse urban community in Harlem, NYC (Hebert et al., 2008, p. 540). 1. Care consisted of assessment by a nurse case manager before patient discharge of post discharge, supplying with relevant educational materials; 2. A visiting service by the Nurse Case Manager before discharge to discuss the post discharge regimen; 3. A clinic appointment within 1 week of discharge; (4) a telephone call from the primary Case Manager Nurse within 2 days of discharge to assess for any existing problems; and (5) reevaluation of the therapeutic plan by the physician and nurse at clinic visits. Client in the nurse managed group maintained higher compliance rate, lower admission rate to acute hospitals with CHF related complications, and higher adherence to physical exercising.


Hickman, D. H., Weiss, J. W., Guise, J., Buckley, D., Motu’apuka, M., Graham, E., Saha, S. (2013). Outpatient Case Management for Adults with Medical Illness and Complex Care Needs. US Department of Health and Human Services. Agency for Healthcare Research and Quality, 1-542. Retrieved from
Lammon, C. A., Stanton, M. P., & Blakney, J. L. (2010). Innovative Partnerships: The Clinical Nurse Leader Role in Diverse Care Settings. Journal of Professional Nursing, 5, 258-263.

Hebert, P. L., & Sisk, J. E. (2008). Challenges Facing Nurse-Led Disease Management for Heart Failure. Disease Manage Health Outcome, 16(1-16), 1-16.

Hebert, P. L., Sisk, J. E., Wang, J. J., Tuzzio, L., Casabianca, J. M., Chassin, M. R., ... McLaughlin, M. A. (2008). Cost-Effectiveness of Nurse-Led Disease Management for Heart Failure in an Ethnically Diverse Urban Community. American College of Physicians, 149, 540-548.

Tahan, H. A., & Campagna, V. (2010). Case Management Roles and Functions Across Various Settings and Professional Disciplines. Professional Case Management, 15, 245-277. Retrieved from

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