Public Health Nursing Vol. 31 No. 1, pp. 36–43 0737-1209/© 2013 Wiley Periodicals, Inc. doi: 10.1111/phn.12049
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The Development of a Community and Home-Based Chronic Care Management Program for Older Adults Jennifer Cooper, M.S.N., R.N., A.P.H.N.-B.C., C.C.P., and Kathryn A. McCarter, M.S.H.A., R.N., C.C.P. North Penn Visiting Nurse Association, Lansdale, Pennsylvania Correspondence to: Jennifer Cooper, North Penn Visiting Nurse Association, 51 Medical Campus Dr., Lansdale, PA 19446. E-mail: [email protected]
ABSTRACT Objective: The objective of this paper was to evaluate a chronic care management program piloted by a visiting nurses association. Desired outcomes were to increase nurses knowledge of self-management of chronic conditions and improve patient self-efficacy and clinical measures. Program Plan and Implementation: The program provided educational development for nurses and piloted encounters with patients with chronic conditions targeting community health nurses for a chronic care professional (CCP) certification and invited 300 faith community nurses to an education program on chronic condition(s). Thirteen patients with chronic condition(s) were enrolled. Chronic care professional modules were used to increase nurses knowledge and were measured by successful completion of a certification exam. Faith community nurses participated in an education program and completed a posttest to measure knowledge of content. Patient improvement in self-management was measured by pre- and postintervention self-efficacy scores and clinical measures. Program Evaluation: Seventeen nurses successfully completed the exam, and 38 faith community nurses participated in the program and completed the posttest. Three patients showed improvement in self-efficacy scores and eight in clinical measures. Conclusions: The educational development of community nurses prepared them to provide effective encounters to improve self-efficacy and clinical outcomes for older adults with chronic conditions. Key words: aging, certification, chronic illness, community health nursing, disease management, home health care, parish/faith community nursing.
Public health successes in the eradication and mitigation of infectious diseases in the 20th century have posed new challenges today for those aging with chronic disease (also used interchangeably with the term “chronic conditions” to include conditions related or secondary to the disease, e.g., fatigue or depression). Chronic disease is most prevalent in the older adult population and is the leading cause of pain, disability, death and overall loss of function, independence, and quality of life (Center for Disease Control and Prevention [CDC] and the Merck Company Foundation, 2007). Although medical advances support longevity, 80% of older adults live with at least one chronic condition, while 50% live with two or more (CDC,
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2007). In addition, older adults disproportionately account for higher percentages of health utilization (e.g., physician office visits, hospital outpatient visits, hospital stays, prescriptions, emergency medical services, and nursing home use) are vulnerable to “geriatric syndromes” (e.g., delirium, depression, sensory impairment, incontinence, malnutrition, osteoporosis, falls, and fall-related injuries), and have greater limitations with activities of daily living than the general population (Institute of Medicine, 2008). These health needs are what frequently send older adults to physician offices and emergency rooms where chronic conditions are neither effectively nor efficiently treated (Holman & Lorig, 2004). Such trends call for a focus on
Cooper and McCarter: Chronic Care Management chronic rather than acute conditions among the older adult population. Therefore, chronic care management among this population is a tertiary prevention strategy meant to improve quality of life and maintain independence for those likely to live in the community well into old age with comorbid conditions. Diseases such as heart disease (e.g., congestive heart failure), respiratory disease (e.g., emphysema), and stroke are defined as chronic because they generally last more than 1 year, limit activities of daily living, require ongoing care, and are typically progressive (Institute Health Sciences Institute, 2008). With chronic conditions, long-lasting and lifechanging physical and emotional symptoms feed on each other, creating a “vicious cycle” (Lorig, Sobel, Gonzalez, & Minor, 2006, p. 3) that is only broken by effective techniques to manage the symptoms. The North Penn Visiting Nurse Association (NPVNA) of Lansdale, PA has provided a full continuum of health care services to the community since 1919, including child and adult health clinics, dental clinics, home care, adult day services, hospice, meals on wheels, and community health education. By nature of the services provided, a majority of patients receiving services from the NPVNA are over the age of 65. A 2010 community assessment determined that chronic conditions were affecting more than 60% of the state’s population (Pennsylvania Homecare Association, 2010), approximately 21% of those living in the NPVNA service area, 64% of NPVNA home care admissions, and 30% of patients seen in a NPVNA community screening sites (Public Health Management Corporation, 2010). The NPVNA sensed a shift from acute to chronic conditions among their patients, as hypertension and congestive heart failure were the most commonly seen conditions both within their community screenings and home care services. 2010 third-quarter data from the Home Care telehealth program patients (n = 83) revealed that 43% of patients had congestive heart failure, 40% with a diagnosis of other heart problems (i.e., hypertension, atrial fibrillation or postsurgery coronary bypass graft, or valve replacement), and 17% with chronic obstructive pulmonary disease or other chronic respiratory issues. 2009–2010 Community Health Education (CHE) records of blood pressure screenings showed that more than 300 community blood pressure screenings were offered, screening
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over 4800 people. Of those screened in May 2010 alone (n = 451), 70% were over age 65 and 30% of those had readings >140/90 mm/hg. Precursors to the subsequent development of the NPVNA Chronic Care Management (CCM) Program included attendance by the NPVNA Home Care and Community Health Education Directors at the February 2010 Pennsylvania Home Care Association’s presentation on chronic care management training that focused on the home-based chronic care model developed and piloted in Baptist Health Systems of Arkansas, an April 2010 presentation on the white paper entitled The Delineation of Home Health Care: The Natural Evolution of a Healthy Industry (Matas, 2010), and a May 2010 regional symposium on reducing hospital admission featuring speakers, Eric Coleman and Mary Naylor. Discussion on effective transitional care interventions programs, such as the Care Transitions Program founded by Dr. Eric Coleman of the University of Colorado and the Transitional Care Model developed by Dr. Mary Naylor of the University of Pennsylvania demonstrated the use of advanced practice nurses in patient interaction while they are still in the hospital, followed by intense interaction with the patient for the first 4–6 weeks post discharge. These interactions focus on empowering the patient to adhere to postdischarge instructions for medication, symptom and self-care management, and follow through with their primary care providers (Brown, 2009). In addition, further review of promising chronic care models revealed two programs that have successfully shown a decrease in hospitalizations and improvement in overall outcomes for Medicare beneficiaries with multiple chronic conditions: (1) Dr. Edward G. Wagner’s Chronic Care Model and (2) Dr. Kate Lorig’s Chronic Disease Self-Management Program (CDSMP) (Brown, 2009). Wagner’s Chronic Care Model introduced practice change and the value of patient-provider interactions as a means for improving chronic care outcomes (Improving Chronic Illness Care, 2011). One important premise of this model is that there are many system deficiencies in the current management of chronic conditions, including rushed practitioners not following established practice guidelines, lack of care coordination and active follow-up to ensure the best outcomes, and patients inadequately trained to manage their illnesses (Improving Chronic Illness Care, 2011). These noted deficiencies are areas of
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opportunity for community health providers to step into the role of chronic disease manager. In 1986, Dr. Kate Lorig and associates at the Stanford University Patient Education Research Center began the research and development of what is now the nationally utilized CDSMP. The program model is a 6-week, peer-led workshop that teaches those with chronic conditions to self-manage their symptoms through a variety of skills and techniques, including pain and fatigue management, breathing techniques, managing emotions, relaxation, nutrition, exercise, medication management, and communication with health care providers (Lorig et al., 2006). Randomized-controlled trials of the CDSMP have shown significant outcomes and cost-effectiveness related to health outcomes, health utilization, and self-efficacy (Lorig et al., 1999) and the CDSMP program has been federally funded and disseminated throughout the United States by Stanfordlicensed trainers. Wagner’s model of planned, proactive encounters, along with the concepts of self-efficacy and self-management from Lorig’s CDSMP were the foundational evidence-base for the NPVNA’s CCM program. Knowledge of these effective chronic care models and analysis of their own data and trends prompted discussion on how the NPVNA, as a long-standing provider of home and community services, could contribute to the overall management of chronic health needs among older adults in their service area. The NPVNA Directors considered all of these elements and incorporated key concepts into the creation of a chronic care management program that included chronic care professional training for their nurses and a pilot program of nurse-patient interventions with NPVNA patients with chronic conditions. The idea of a NPVNA CCM program was presented to and approved by the NPVNA Board of Directors in June 2010 and included in the 2010/2011 strategic plan. The NPVNA’s CHE Department was tasked with designing and piloting a CCM program within the 2010/ 2011 fiscal year and presenting a plan for full program implementation for the 2011/2012 fiscal year to the Board of Directors in June 2011.
Methods With a continuum of home and community services available, the goal of the NPVNA CCM program was
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that all community members, both those at risk and those diagnosed with chronic disease, would have access to preventative and supportive care to help them effectively manage their chronic condition. Program objectives were to (1) utilize and increase home care, community health and faith community nurses’ knowledge of aging, chronic conditions, and self-management and (2) identify and enroll 30 (15 home care/episodic and 15 from the community/ pre- and postepisodic) patients with chronic conditions in the pilot program to provide health coaching by a trained nurse to improve self-efficacy and clinical measures (i.e., blood pressure, weight, pulse, and/or blood glucose level). By developing the nurses’ knowledge of aging, chronic conditions, and patient self-management, it was hypothesized that planned and proactive nurse-patient encounters, as posited by Wagner’s model, would improve patient chronic disease self-efficacy. Lorig et al.’s (1999) research showed that if self-efficacy is improved, patients have greater potential to self-manage chronic conditions, thus improving their health outcomes and decreasing the amount and unnecessary use of health services. The Faith Community Nurse (FCN) role (also known as “Parish Nurse”) was an important consideration in the CCM program. This unique nursing role evolved from the vision and work of the late Rev. Granger E. Westberg and is now clearly defined through the American Nurses Association’s (ANA) Scope and Standards of Practice, where nurses function as health educators, counselors, volunteer coordinators, liaisons to community health services, and promoters of illness prevention and wholistic health (ANA, 2012; Westberg, 1990). In the NPVNA community, Faith Community Nurses were known to be a long-standing cadre of trusted health professionals who had regular contact with congregants/parishioners with chronic conditions. It was also known from NPVNA community screenings that many economically disadvantaged and ethnically diverse older adults choose to participate in health screenings at their faith communities rather than any other public venue, such as senior center, residential facility, or retail area. For these reasons, along with the nontraditional approach to wellness (vs. sick) care, it was imperative to include FCNs in the program and it allowed the NPVNA to provide a greater reach and fuller continuum of care for patients as
Cooper and McCarter: Chronic Care Management they transitioned beyond home or community programs with chronic conditions. The home care, community health, and faith community nurses targeted for educational development within this pilot program had a similar practice focus and encounters with patients in the community; therefore, they were well positioned to provide this intervention. However, a major consideration in the program development was that their roles, scope of practice, and services provided by the nurses were very different. Our experience is that many of the faith community nurses in the region are unpaid volunteers and are unable to commit the time and expense of a chronic care professional certification training, so while the option to complete the certification was available to them, the educational intervention and expectations of piloting the nurse-patient encounters was planned differently than that of the NPVNA staff nurses.
Educational development of nurses The educational development of NPVNA Home Care and Community Health Nurses included the use of the CCP program modules and certification exam from HealthSciences Institute (Institute Health Sciences Institute, 2008). In August 2010, the NPVNA enrolled 17 nurses and began to offer the CCP modules to Home Care and Community Health Nurses as a discussion forum held during the time of their monthly team meetings. The objective for the educational development was that all 17 Community Health and Home Care nurses targeted for CCP Certification completed the modules and received a 75% or better on the final exam. In February 2011, a half-day continuing education program entitled “New Perspectives on Chronic Care Management” was created by the NPVNA and offered to local Faith Community Nurses. The objective was that at least 10% of Faith Community nurses invited (from a list of approximately 300 regional Faith Community nurses) would attend this program and demonstrate knowledge of aging and chronic conditions by completing a seminar posttest. Patient participation Phase one of the CCM program was a pilot program that ran from April 1, 2011 to December 31, 2011. The pilot program included an observational,
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cross-sectional evaluation of a group of NPVNA patients with similar characteristics available at this point in time. The patients included in the pilot program are a nonrandomized, convenience sample referred to the program. To be included in the CCM program, patients had to have one or more physician-diagnosed chronic conditions. The nurse-patient encounters involved coordinated preepisodic (preventative/community-based), episodic (acute disease state/home care visits), and/or postepisodic (following acute disease state/ home or community-based) interventions by nurses who function as Chronic Care Managers in the home and community. The NPVNA first developed a method for Home Care Nurses, Community Health Nurses, Faith Community Nurses, and local physician practices to refer patients into the CCM Program. Secondly, the NPVNA Home Care Nurses sought to screen and enroll 15 patients during the home care episode. They would then initiate clinical pathways and care plans related to the patients’ chronic condition(s) and implementing motivational interviewing and coaching techniques to support the patient as they developed goals for better self-management of their illness. Upon discharge, the patient was referred to the community-based program. The Community Health Nurses sought to enroll 15 patients and provide one-on-one encounters with patients for 8 weeks with the hope that patients would show evidence of enhanced selfmanagement skills by completing an action plan, weekly documentation that they were following the plan, and evidence of enhanced self-management skills by scoring at least 30% higher on self-efficacy postassessment. Potential CCM patients were screened at the time of referral to home care for the presence of one of the top chronic illness diagnoses as described by the HealthSciences Institute (Institute Health Sciences Institute, 2008) and/or the CDC (2012), including asthma, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, diabetes, and hypertension. If appropriate at the time of admission, the admitting nurse completed a hospitalization risk assessment, identifying if the patient met the selection criteria for enrollment into the program. The use of appropriate CCM pathways, educational materials, and patient centric care/action plans were then fully implemented as an integral part of the patient’s care. While assessing
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the risk and ongoing chronic care needs was the critical component of the home care portion of the CCM program, it was reliant on the length of funding of home care services. Therefore, the ability to refer the patient to the community portion of the program at the time of discharge was imperative. Community patients were referred to the CCM program through four portals: physician practices, community health screenings, home care, and faith community nurses. By partnering with professionals across a variety of settings, patients who would benefit most from nurse-patient encounters that provided coaching related to chronic care management were identified. A referral form was created for use of those professionals within these four portals to gather preliminary patient information and additionally acted as signed permission for the patient to be contacted by a nurse offering the CCM program. Because the partnership between the NPVNA and primary care practice was identified as both as preventative and as a way to help coordinate patient care, the NPVNA invested time to sit face to face with two physicians from two local practices to discuss the program and explore what the partnership and referral process would look like. The two practices were very open to making referrals. For the community portion of the pilot, the chronic disease self-efficacy assessment, a valid and reliable Stanford CDSMP tool (found within the NPVNA’s Cerner Homeworks software), was administered to assess self-rated self-efficacy scores and pre- and postintervention self-efficacy scores were compared to determine if there was improvement. The NPVNA created an action plan form to guide nurses’ discussion and that was usable for patient goal-setting and data collection. Initially, the nurse used this form, working with patients to write out their own health goals, an action plan to reach those health goals, questions for their health care provider, and their medications. If it was determined during the weekly encounters that the individual health goals were presenting difficulty or not being met by the patient, the nurse helped the patient revise their goals by developing new action steps. Patient clinical measures, including blood pressure, weight, pulse, and blood glucose (as identified by patient related to their chronic condition and health goals) were collected and entered into an Excel spreadsheet. In addition, the spreadsheet
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included the patients’ chronic disease(s) type, ethnicity, sex, age, self-efficacy scores, and referral source (e.g., senior center, home care, physician practice, faith community). The NPVNA explored the use of the current Cerner Homeworks Software program that contains a “Care Management Dashboard” application that would allow the NPVNA to create specific templates to capture agency-defined performance measures. Data entered into Homeworks can be organized and allow the team to generate reports on prevalence and types of chronic conditions, average self-efficacy scores, changes in scores over time, and health utilization patterns for the population. The community nurse-patient encounters took place in community settings, such as senior centers, the NPVNA, fitness clubs, food pantries, retail blood pressures screening sites, faith communities, or senior housing sites. These sites were specifically selected to facilitate access to care for the underserved, underinsured, and uninsured members of the community and were places that Community Health Nurses were already seeing patients one-onone for blood pressure screenings or for support groups. It was necessary to conduct some encounters telephonically if the discharged home care patient was still homebound. The cost CCM program, including HealthSciences materials and exam and completion of the pilot program, was covered under the NPVNA operational expenses and as such, was sufficiently funded. No additional staff or staff time were added, as the program was intended to be the restructuring and retooling of current services.
Results Nurse knowledge By May 31, 2011, the CCP training was completed by 17 Home Care and Community Health Nurses and 100% of the nurses passed the certification exam with scores greater than 75%. The successful completion of the certification by all nurses allowed the NPVNA to become a fully accredited Chronic Care Professional organization. This accreditation allows the NPVNA to further differentiate itself in the market with a comprehensive program that maximizes the mission-driven continuum of health care services.
Cooper and McCarter: Chronic Care Management Thirty-eight of approximately 300 Faith Community nurses from the NPVNA listserv participated in the continuing education program and 100% completed the posttest. Continuing education programs related to chronic conditions continued to be offered by the NPVNA throughout 2011.
Patient participation At the conclusion of the pilot program period, there were 13 total participants in the community-based CCM pilot program, with 11 completing the program within the pilot period. Seven patients from home care were provided the opportunity to continue the program through the community-based CCM program, but only one chose to do so. Five patients showed improvement in their self-efficacy scores, and eight patients demonstrated improvement in their clinical measurements (see Table 1 for self-efficacy scores and clinical measures).
Discussion The management of chronic conditions is a population-wide need among older adults, and therefore
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needs a population-focused approach to find solutions. Although chronic care management interventions have proven to effectively meet the needs of those with chronic conditions, they are often underrecognized, underutilized, and underfunded in a reactive and cure-focused health care system. The beauty of the chronic care model is that it is able to fit into existing community programs, needs, and strengths. The community health nursing role with the chronic care model was critical in the development and coordination of a program needed to support older adults with chronic conditions as they transitioned beyond home care. Using their skills in analytical assessment, determining multiple determinants of health, and building community partnerships, community health nurses were able to identify the “touch points” in the community where older adults frequent and could most benefit from a community-based chronic care management program. The NPVNA built on existing relationships with local Faith Communities and their nurses, three local Senior Centers, and Primary Care Physician Offices to help ensure program growth and sustainability. Working with such partners allowed the NPVNA to provide a fuller continuum of care and
TABLE 1. CCM Pilot Program Patient Outcomes Clinical measures Self-efficacy scores
Blood pressure (mmHg)
Weight (lbs.)
Results Clinical measures
Patients
Referral source
Pretest
Posttest
Pretest
Posttest Pretest Posttest
Self-efficacy
1 2 3 4 5 6 7
Community: retail Physician Community: Residential Faith community Community: Food cupboard Community: Fitness club Community: NPVNA diabetes support group
8.8 7.7 6.9 4.9 8.3 7.4 7.1
8.9 N/A 5.9 8.2 7.9 8.9 N/A
162/84 134/68 156/96 150/80 150/90 174/90 142/90
120/84 N/A 140/82 130/74 N/A 132/82 148/58
254 193.5 N/A N/A N/A N/A 420
237 N/A N/A N/A N/A N/A 415.5
Improved Incomplete Declined Improved Declined Improved Incomplete
Community: Residential Community: Retail Community: NPVNA diabetes support group Home care Senior center Community: Retail
8.8 9.6 N/A
8.8 7.8 N/A
158/80 130/95 144/80
150/76 132/90 168/86
N/A N/A N/A
N/A N/A N/A
No change Declined Incomplete
Improved Incomplete Improved Improved Incomplete Improved Declined BP improved Wt. Improved Declined Declined
N/A 8.3 9.6
N/A 9.0 9.9
128/80 170/90 132/78
N/A 150/88 124/82
N/A N/A N/A
N/A N/A N/A
Incomplete Improved Improved
Incomplete Improved Improved
8 9 10 11 12 13
Note. BP = Blood Pressure; Wt. = Weight.
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care coordination to better identify and support those with chronic conditions. These community partnerships provided (1) multiple points of referral from the community into the program (i.e., physician practice to CCM program, home care to CCM program, faith communities to CCM program) and from the program into the community (e.g., Stanford CDSMP workshops) or other NPVNA programs (e.g., adult clinics, adult day services, or hospice) and (2) helped to foster relationships among other community health service providers and primary care, which contributes to eliminating barriers to accessing care and fragmented care. The partnerships have allowed the NPVNA to successfully influence practice change at the home and community level where adults live their daily lives with the challenges of aging and chronic conditions. Through the program development, faith communities and senior centers were identified as options for providing ongoing chronic care support through group intervention, such as the Stanfordlicensed CDSMP workshop. There were no Stanford CDSMP’s being offered in the NPVNA service area at the time of this pilot program, but the requirements for training by a Stanford-licensed provider were being explored. We recommend identifying such workshops in the community to support a chronic care management program. A lesson we learned in working with physician practices was that the physician needed to be fully educated about the value of the program to identify and encourage patients to participate. Secondly, there needed to be more consistent contact and follow through between the NPVNA and patient referred by a physician to maintain the engagement and commitment of both. In this suburban community where public transportation is limited, transportation was a recurring barrier influencing patients’ participation in the pilot program. Because the community-based component of the intervention could not be provided in the home, some patients had difficulty regularly getting to community sites, so therefore had difficulty meeting with the nurse for timely assessment of clinical measurements and review of action plans. The NPVNA attempted to remedy this by targeting community settings where transportation is most accessible (e.g., senior centers, shopping areas, faith communities, senior housing). Enrolling postepisod-
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ic home care patients presented some difficulty, as many of the patients were still homebound and unable to meet with the nurse in a community setting. Getting patients to agree and stay motivated to continue the home/episodic program into the community/postepisodic program was difficult at times if the initial outreach to the patient by the community nurse was delayed for any reason. All of these issues were addressed during the phase two or implementation year of the program, including more careful adherence to patient selection criteria and the development of better reporting tools to the patient primary care physician. Throughout the program planning, there was a necessary consideration of the older adults’ cognitive, literacy, cultural, and sensory needs, along with a balanced view of aging through a lens of strengths rather than deficits. Focus on strengths is especially important within an intervention where the goal is to increase self-efficacy. Nurses needed to consider each patient’s level of knowledge and confidence, plan their encounters according to sensory and literacy needs, and creatively find ways to encourage them to be actively involved in their health care. This coaching was meant to create active partnerships rather than passive or paternal relationships between nurses and patients (Institute Health Sciences Institute, 2008). Overall, the NPVNA-piloted CCM program became the impetus for retooling and restructuring a well-established home and community health provider, now better positioned to meet the needs of a changing patient population and health care delivery system.
References American Nurses Association. (2012). Faith community nursing scope and standards of practice (2nd ed.). Silver Spring, MD: Nursebooks.org. Brown, R. (2009). The promise of care coordination: Models that decrease hospitalizations and improve outcomes for medicare beneficiaries with chronic illnesses. Princeton, NJ: Mathematica Policy Research. Retrieved from http:// www.nyam.org/social-work-leadership-institute/docs/N3C-Promise-of-Care-Coordination. pdf Center for Disease Control and Prevention [CDC] and the Merck Company Foundation. (2007). The state of aging and health in America
Cooper and McCarter: Chronic Care Management 2007. Whitehouse Station, NJ: The Merck Company Foundation. Holman, H., & Lorig, K. (2004). Patient self-management: A key to effectiveness and efficiency in care of chronic disease. Public Health Reports, 119, 239–243. Improving Chronic Illness Care. (2011). The chronic care model. Retrieved from http://www.im provingchroniccare.org/index.php?p=The_ Chronic_Care_Model&s=2 Institute Health Sciences Institute. (2008). Chronic care professional (CCP) certification program manual. Chicago, IL: HealthSciences Institute. Institute of Medicine. (2008). Retooling for an aging America: Building the health care workforce. Washington, DC: National Academies Press. Lorig, K., Sobel, D., Gonzalez, V., & Minor, M. (2006). Living a healthy life with chronic conditions. Colorado: Bull Publishing Company. Lorig, K. R., Sobel, David., Stewart, A., Brown, Byron. W., Bandura, A., Ritter, P., et al.
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(1999). Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: A randomized trial. Medical Care, 37(1), 5–14. Matas, W. & Associates. (2010). The delineation of home health care: The Natural Evolution of a Healthy Industry (White Paper). Retrieved from http://www.wyattmatas.com/mimik/mi mik_uploads/white_papers/7/The%20Delinea tion%20of%20Home%20Healthcare%20Final %20041210.pdf Pennsylvania Homecare Association. (2010). Effective partners: Home health’s role in chronic care management (White Paper). Retrieved from http://www.pahomecare.org/pdf/White paper_Final.pdf Public Health Management Corporation. (2010). Community health database. Retrieved from http://www.chdbdata.org Westberg, Granger. E. (1990). The parish nurse: Providing a minister of health for your congregation. Minneapolis, MN: Augsburg Fortress.
POPULATIONS
AT
RISK ACROSS
THE
LIFESPAN: PROGRAM EVALUATIONS
The Development of a Community and Home-Based Chronic Care Management Program for Older Adults Jennifer Cooper, M.S.N., R.N., A.P.H.N.-B.C., C.C.P., and Kathryn A. McCarter, M.S.H.A., R.N., C.C.P. North Penn Visiting Nurse Association, Lansdale, Pennsylvania Correspondence to: Jennifer Cooper, North Penn Visiting Nurse Association, 51 Medical Campus Dr., Lansdale, PA 19446. E-mail: [email protected]
ABSTRACT Objective: The objective of this paper was to evaluate a chronic care management program piloted by a visiting nurses association. Desired outcomes were to increase nurses knowledge of self-management of chronic conditions and improve patient self-efficacy and clinical measures. Program Plan and Implementation: The program provided educational development for nurses and piloted encounters with patients with chronic conditions targeting community health nurses for a chronic care professional (CCP) certification and invited 300 faith community nurses to an education program on chronic condition(s). Thirteen patients with chronic condition(s) were enrolled. Chronic care professional modules were used to increase nurses knowledge and were measured by successful completion of a certification exam. Faith community nurses participated in an education program and completed a posttest to measure knowledge of content. Patient improvement in self-management was measured by pre- and postintervention self-efficacy scores and clinical measures. Program Evaluation: Seventeen nurses successfully completed the exam, and 38 faith community nurses participated in the program and completed the posttest. Three patients showed improvement in self-efficacy scores and eight in clinical measures. Conclusions: The educational development of community nurses prepared them to provide effective encounters to improve self-efficacy and clinical outcomes for older adults with chronic conditions. Key words: aging, certification, chronic illness, community health nursing, disease management, home health care, parish/faith community nursing.
Public health successes in the eradication and mitigation of infectious diseases in the 20th century have posed new challenges today for those aging with chronic disease (also used interchangeably with the term “chronic conditions” to include conditions related or secondary to the disease, e.g., fatigue or depression). Chronic disease is most prevalent in the older adult population and is the leading cause of pain, disability, death and overall loss of function, independence, and quality of life (Center for Disease Control and Prevention [CDC] and the Merck Company Foundation, 2007). Although medical advances support longevity, 80% of older adults live with at least one chronic condition, while 50% live with two or more (CDC,
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2007). In addition, older adults disproportionately account for higher percentages of health utilization (e.g., physician office visits, hospital outpatient visits, hospital stays, prescriptions, emergency medical services, and nursing home use) are vulnerable to “geriatric syndromes” (e.g., delirium, depression, sensory impairment, incontinence, malnutrition, osteoporosis, falls, and fall-related injuries), and have greater limitations with activities of daily living than the general population (Institute of Medicine, 2008). These health needs are what frequently send older adults to physician offices and emergency rooms where chronic conditions are neither effectively nor efficiently treated (Holman & Lorig, 2004). Such trends call for a focus on
Cooper and McCarter: Chronic Care Management chronic rather than acute conditions among the older adult population. Therefore, chronic care management among this population is a tertiary prevention strategy meant to improve quality of life and maintain independence for those likely to live in the community well into old age with comorbid conditions. Diseases such as heart disease (e.g., congestive heart failure), respiratory disease (e.g., emphysema), and stroke are defined as chronic because they generally last more than 1 year, limit activities of daily living, require ongoing care, and are typically progressive (Institute Health Sciences Institute, 2008). With chronic conditions, long-lasting and lifechanging physical and emotional symptoms feed on each other, creating a “vicious cycle” (Lorig, Sobel, Gonzalez, & Minor, 2006, p. 3) that is only broken by effective techniques to manage the symptoms. The North Penn Visiting Nurse Association (NPVNA) of Lansdale, PA has provided a full continuum of health care services to the community since 1919, including child and adult health clinics, dental clinics, home care, adult day services, hospice, meals on wheels, and community health education. By nature of the services provided, a majority of patients receiving services from the NPVNA are over the age of 65. A 2010 community assessment determined that chronic conditions were affecting more than 60% of the state’s population (Pennsylvania Homecare Association, 2010), approximately 21% of those living in the NPVNA service area, 64% of NPVNA home care admissions, and 30% of patients seen in a NPVNA community screening sites (Public Health Management Corporation, 2010). The NPVNA sensed a shift from acute to chronic conditions among their patients, as hypertension and congestive heart failure were the most commonly seen conditions both within their community screenings and home care services. 2010 third-quarter data from the Home Care telehealth program patients (n = 83) revealed that 43% of patients had congestive heart failure, 40% with a diagnosis of other heart problems (i.e., hypertension, atrial fibrillation or postsurgery coronary bypass graft, or valve replacement), and 17% with chronic obstructive pulmonary disease or other chronic respiratory issues. 2009–2010 Community Health Education (CHE) records of blood pressure screenings showed that more than 300 community blood pressure screenings were offered, screening
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over 4800 people. Of those screened in May 2010 alone (n = 451), 70% were over age 65 and 30% of those had readings >140/90 mm/hg. Precursors to the subsequent development of the NPVNA Chronic Care Management (CCM) Program included attendance by the NPVNA Home Care and Community Health Education Directors at the February 2010 Pennsylvania Home Care Association’s presentation on chronic care management training that focused on the home-based chronic care model developed and piloted in Baptist Health Systems of Arkansas, an April 2010 presentation on the white paper entitled The Delineation of Home Health Care: The Natural Evolution of a Healthy Industry (Matas, 2010), and a May 2010 regional symposium on reducing hospital admission featuring speakers, Eric Coleman and Mary Naylor. Discussion on effective transitional care interventions programs, such as the Care Transitions Program founded by Dr. Eric Coleman of the University of Colorado and the Transitional Care Model developed by Dr. Mary Naylor of the University of Pennsylvania demonstrated the use of advanced practice nurses in patient interaction while they are still in the hospital, followed by intense interaction with the patient for the first 4–6 weeks post discharge. These interactions focus on empowering the patient to adhere to postdischarge instructions for medication, symptom and self-care management, and follow through with their primary care providers (Brown, 2009). In addition, further review of promising chronic care models revealed two programs that have successfully shown a decrease in hospitalizations and improvement in overall outcomes for Medicare beneficiaries with multiple chronic conditions: (1) Dr. Edward G. Wagner’s Chronic Care Model and (2) Dr. Kate Lorig’s Chronic Disease Self-Management Program (CDSMP) (Brown, 2009). Wagner’s Chronic Care Model introduced practice change and the value of patient-provider interactions as a means for improving chronic care outcomes (Improving Chronic Illness Care, 2011). One important premise of this model is that there are many system deficiencies in the current management of chronic conditions, including rushed practitioners not following established practice guidelines, lack of care coordination and active follow-up to ensure the best outcomes, and patients inadequately trained to manage their illnesses (Improving Chronic Illness Care, 2011). These noted deficiencies are areas of
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opportunity for community health providers to step into the role of chronic disease manager. In 1986, Dr. Kate Lorig and associates at the Stanford University Patient Education Research Center began the research and development of what is now the nationally utilized CDSMP. The program model is a 6-week, peer-led workshop that teaches those with chronic conditions to self-manage their symptoms through a variety of skills and techniques, including pain and fatigue management, breathing techniques, managing emotions, relaxation, nutrition, exercise, medication management, and communication with health care providers (Lorig et al., 2006). Randomized-controlled trials of the CDSMP have shown significant outcomes and cost-effectiveness related to health outcomes, health utilization, and self-efficacy (Lorig et al., 1999) and the CDSMP program has been federally funded and disseminated throughout the United States by Stanfordlicensed trainers. Wagner’s model of planned, proactive encounters, along with the concepts of self-efficacy and self-management from Lorig’s CDSMP were the foundational evidence-base for the NPVNA’s CCM program. Knowledge of these effective chronic care models and analysis of their own data and trends prompted discussion on how the NPVNA, as a long-standing provider of home and community services, could contribute to the overall management of chronic health needs among older adults in their service area. The NPVNA Directors considered all of these elements and incorporated key concepts into the creation of a chronic care management program that included chronic care professional training for their nurses and a pilot program of nurse-patient interventions with NPVNA patients with chronic conditions. The idea of a NPVNA CCM program was presented to and approved by the NPVNA Board of Directors in June 2010 and included in the 2010/2011 strategic plan. The NPVNA’s CHE Department was tasked with designing and piloting a CCM program within the 2010/ 2011 fiscal year and presenting a plan for full program implementation for the 2011/2012 fiscal year to the Board of Directors in June 2011.
Methods With a continuum of home and community services available, the goal of the NPVNA CCM program was
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that all community members, both those at risk and those diagnosed with chronic disease, would have access to preventative and supportive care to help them effectively manage their chronic condition. Program objectives were to (1) utilize and increase home care, community health and faith community nurses’ knowledge of aging, chronic conditions, and self-management and (2) identify and enroll 30 (15 home care/episodic and 15 from the community/ pre- and postepisodic) patients with chronic conditions in the pilot program to provide health coaching by a trained nurse to improve self-efficacy and clinical measures (i.e., blood pressure, weight, pulse, and/or blood glucose level). By developing the nurses’ knowledge of aging, chronic conditions, and patient self-management, it was hypothesized that planned and proactive nurse-patient encounters, as posited by Wagner’s model, would improve patient chronic disease self-efficacy. Lorig et al.’s (1999) research showed that if self-efficacy is improved, patients have greater potential to self-manage chronic conditions, thus improving their health outcomes and decreasing the amount and unnecessary use of health services. The Faith Community Nurse (FCN) role (also known as “Parish Nurse”) was an important consideration in the CCM program. This unique nursing role evolved from the vision and work of the late Rev. Granger E. Westberg and is now clearly defined through the American Nurses Association’s (ANA) Scope and Standards of Practice, where nurses function as health educators, counselors, volunteer coordinators, liaisons to community health services, and promoters of illness prevention and wholistic health (ANA, 2012; Westberg, 1990). In the NPVNA community, Faith Community Nurses were known to be a long-standing cadre of trusted health professionals who had regular contact with congregants/parishioners with chronic conditions. It was also known from NPVNA community screenings that many economically disadvantaged and ethnically diverse older adults choose to participate in health screenings at their faith communities rather than any other public venue, such as senior center, residential facility, or retail area. For these reasons, along with the nontraditional approach to wellness (vs. sick) care, it was imperative to include FCNs in the program and it allowed the NPVNA to provide a greater reach and fuller continuum of care for patients as
Cooper and McCarter: Chronic Care Management they transitioned beyond home or community programs with chronic conditions. The home care, community health, and faith community nurses targeted for educational development within this pilot program had a similar practice focus and encounters with patients in the community; therefore, they were well positioned to provide this intervention. However, a major consideration in the program development was that their roles, scope of practice, and services provided by the nurses were very different. Our experience is that many of the faith community nurses in the region are unpaid volunteers and are unable to commit the time and expense of a chronic care professional certification training, so while the option to complete the certification was available to them, the educational intervention and expectations of piloting the nurse-patient encounters was planned differently than that of the NPVNA staff nurses.
Educational development of nurses The educational development of NPVNA Home Care and Community Health Nurses included the use of the CCP program modules and certification exam from HealthSciences Institute (Institute Health Sciences Institute, 2008). In August 2010, the NPVNA enrolled 17 nurses and began to offer the CCP modules to Home Care and Community Health Nurses as a discussion forum held during the time of their monthly team meetings. The objective for the educational development was that all 17 Community Health and Home Care nurses targeted for CCP Certification completed the modules and received a 75% or better on the final exam. In February 2011, a half-day continuing education program entitled “New Perspectives on Chronic Care Management” was created by the NPVNA and offered to local Faith Community Nurses. The objective was that at least 10% of Faith Community nurses invited (from a list of approximately 300 regional Faith Community nurses) would attend this program and demonstrate knowledge of aging and chronic conditions by completing a seminar posttest. Patient participation Phase one of the CCM program was a pilot program that ran from April 1, 2011 to December 31, 2011. The pilot program included an observational,
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cross-sectional evaluation of a group of NPVNA patients with similar characteristics available at this point in time. The patients included in the pilot program are a nonrandomized, convenience sample referred to the program. To be included in the CCM program, patients had to have one or more physician-diagnosed chronic conditions. The nurse-patient encounters involved coordinated preepisodic (preventative/community-based), episodic (acute disease state/home care visits), and/or postepisodic (following acute disease state/ home or community-based) interventions by nurses who function as Chronic Care Managers in the home and community. The NPVNA first developed a method for Home Care Nurses, Community Health Nurses, Faith Community Nurses, and local physician practices to refer patients into the CCM Program. Secondly, the NPVNA Home Care Nurses sought to screen and enroll 15 patients during the home care episode. They would then initiate clinical pathways and care plans related to the patients’ chronic condition(s) and implementing motivational interviewing and coaching techniques to support the patient as they developed goals for better self-management of their illness. Upon discharge, the patient was referred to the community-based program. The Community Health Nurses sought to enroll 15 patients and provide one-on-one encounters with patients for 8 weeks with the hope that patients would show evidence of enhanced selfmanagement skills by completing an action plan, weekly documentation that they were following the plan, and evidence of enhanced self-management skills by scoring at least 30% higher on self-efficacy postassessment. Potential CCM patients were screened at the time of referral to home care for the presence of one of the top chronic illness diagnoses as described by the HealthSciences Institute (Institute Health Sciences Institute, 2008) and/or the CDC (2012), including asthma, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, diabetes, and hypertension. If appropriate at the time of admission, the admitting nurse completed a hospitalization risk assessment, identifying if the patient met the selection criteria for enrollment into the program. The use of appropriate CCM pathways, educational materials, and patient centric care/action plans were then fully implemented as an integral part of the patient’s care. While assessing
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the risk and ongoing chronic care needs was the critical component of the home care portion of the CCM program, it was reliant on the length of funding of home care services. Therefore, the ability to refer the patient to the community portion of the program at the time of discharge was imperative. Community patients were referred to the CCM program through four portals: physician practices, community health screenings, home care, and faith community nurses. By partnering with professionals across a variety of settings, patients who would benefit most from nurse-patient encounters that provided coaching related to chronic care management were identified. A referral form was created for use of those professionals within these four portals to gather preliminary patient information and additionally acted as signed permission for the patient to be contacted by a nurse offering the CCM program. Because the partnership between the NPVNA and primary care practice was identified as both as preventative and as a way to help coordinate patient care, the NPVNA invested time to sit face to face with two physicians from two local practices to discuss the program and explore what the partnership and referral process would look like. The two practices were very open to making referrals. For the community portion of the pilot, the chronic disease self-efficacy assessment, a valid and reliable Stanford CDSMP tool (found within the NPVNA’s Cerner Homeworks software), was administered to assess self-rated self-efficacy scores and pre- and postintervention self-efficacy scores were compared to determine if there was improvement. The NPVNA created an action plan form to guide nurses’ discussion and that was usable for patient goal-setting and data collection. Initially, the nurse used this form, working with patients to write out their own health goals, an action plan to reach those health goals, questions for their health care provider, and their medications. If it was determined during the weekly encounters that the individual health goals were presenting difficulty or not being met by the patient, the nurse helped the patient revise their goals by developing new action steps. Patient clinical measures, including blood pressure, weight, pulse, and blood glucose (as identified by patient related to their chronic condition and health goals) were collected and entered into an Excel spreadsheet. In addition, the spreadsheet
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included the patients’ chronic disease(s) type, ethnicity, sex, age, self-efficacy scores, and referral source (e.g., senior center, home care, physician practice, faith community). The NPVNA explored the use of the current Cerner Homeworks Software program that contains a “Care Management Dashboard” application that would allow the NPVNA to create specific templates to capture agency-defined performance measures. Data entered into Homeworks can be organized and allow the team to generate reports on prevalence and types of chronic conditions, average self-efficacy scores, changes in scores over time, and health utilization patterns for the population. The community nurse-patient encounters took place in community settings, such as senior centers, the NPVNA, fitness clubs, food pantries, retail blood pressures screening sites, faith communities, or senior housing sites. These sites were specifically selected to facilitate access to care for the underserved, underinsured, and uninsured members of the community and were places that Community Health Nurses were already seeing patients one-onone for blood pressure screenings or for support groups. It was necessary to conduct some encounters telephonically if the discharged home care patient was still homebound. The cost CCM program, including HealthSciences materials and exam and completion of the pilot program, was covered under the NPVNA operational expenses and as such, was sufficiently funded. No additional staff or staff time were added, as the program was intended to be the restructuring and retooling of current services.
Results Nurse knowledge By May 31, 2011, the CCP training was completed by 17 Home Care and Community Health Nurses and 100% of the nurses passed the certification exam with scores greater than 75%. The successful completion of the certification by all nurses allowed the NPVNA to become a fully accredited Chronic Care Professional organization. This accreditation allows the NPVNA to further differentiate itself in the market with a comprehensive program that maximizes the mission-driven continuum of health care services.
Cooper and McCarter: Chronic Care Management Thirty-eight of approximately 300 Faith Community nurses from the NPVNA listserv participated in the continuing education program and 100% completed the posttest. Continuing education programs related to chronic conditions continued to be offered by the NPVNA throughout 2011.
Patient participation At the conclusion of the pilot program period, there were 13 total participants in the community-based CCM pilot program, with 11 completing the program within the pilot period. Seven patients from home care were provided the opportunity to continue the program through the community-based CCM program, but only one chose to do so. Five patients showed improvement in their self-efficacy scores, and eight patients demonstrated improvement in their clinical measurements (see Table 1 for self-efficacy scores and clinical measures).
Discussion The management of chronic conditions is a population-wide need among older adults, and therefore
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needs a population-focused approach to find solutions. Although chronic care management interventions have proven to effectively meet the needs of those with chronic conditions, they are often underrecognized, underutilized, and underfunded in a reactive and cure-focused health care system. The beauty of the chronic care model is that it is able to fit into existing community programs, needs, and strengths. The community health nursing role with the chronic care model was critical in the development and coordination of a program needed to support older adults with chronic conditions as they transitioned beyond home care. Using their skills in analytical assessment, determining multiple determinants of health, and building community partnerships, community health nurses were able to identify the “touch points” in the community where older adults frequent and could most benefit from a community-based chronic care management program. The NPVNA built on existing relationships with local Faith Communities and their nurses, three local Senior Centers, and Primary Care Physician Offices to help ensure program growth and sustainability. Working with such partners allowed the NPVNA to provide a fuller continuum of care and
TABLE 1. CCM Pilot Program Patient Outcomes Clinical measures Self-efficacy scores
Blood pressure (mmHg)
Weight (lbs.)
Results Clinical measures
Patients
Referral source
Pretest
Posttest
Pretest
Posttest Pretest Posttest
Self-efficacy
1 2 3 4 5 6 7
Community: retail Physician Community: Residential Faith community Community: Food cupboard Community: Fitness club Community: NPVNA diabetes support group
8.8 7.7 6.9 4.9 8.3 7.4 7.1
8.9 N/A 5.9 8.2 7.9 8.9 N/A
162/84 134/68 156/96 150/80 150/90 174/90 142/90
120/84 N/A 140/82 130/74 N/A 132/82 148/58
254 193.5 N/A N/A N/A N/A 420
237 N/A N/A N/A N/A N/A 415.5
Improved Incomplete Declined Improved Declined Improved Incomplete
Community: Residential Community: Retail Community: NPVNA diabetes support group Home care Senior center Community: Retail
8.8 9.6 N/A
8.8 7.8 N/A
158/80 130/95 144/80
150/76 132/90 168/86
N/A N/A N/A
N/A N/A N/A
No change Declined Incomplete
Improved Incomplete Improved Improved Incomplete Improved Declined BP improved Wt. Improved Declined Declined
N/A 8.3 9.6
N/A 9.0 9.9
128/80 170/90 132/78
N/A 150/88 124/82
N/A N/A N/A
N/A N/A N/A
Incomplete Improved Improved
Incomplete Improved Improved
8 9 10 11 12 13
Note. BP = Blood Pressure; Wt. = Weight.
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care coordination to better identify and support those with chronic conditions. These community partnerships provided (1) multiple points of referral from the community into the program (i.e., physician practice to CCM program, home care to CCM program, faith communities to CCM program) and from the program into the community (e.g., Stanford CDSMP workshops) or other NPVNA programs (e.g., adult clinics, adult day services, or hospice) and (2) helped to foster relationships among other community health service providers and primary care, which contributes to eliminating barriers to accessing care and fragmented care. The partnerships have allowed the NPVNA to successfully influence practice change at the home and community level where adults live their daily lives with the challenges of aging and chronic conditions. Through the program development, faith communities and senior centers were identified as options for providing ongoing chronic care support through group intervention, such as the Stanfordlicensed CDSMP workshop. There were no Stanford CDSMP’s being offered in the NPVNA service area at the time of this pilot program, but the requirements for training by a Stanford-licensed provider were being explored. We recommend identifying such workshops in the community to support a chronic care management program. A lesson we learned in working with physician practices was that the physician needed to be fully educated about the value of the program to identify and encourage patients to participate. Secondly, there needed to be more consistent contact and follow through between the NPVNA and patient referred by a physician to maintain the engagement and commitment of both. In this suburban community where public transportation is limited, transportation was a recurring barrier influencing patients’ participation in the pilot program. Because the community-based component of the intervention could not be provided in the home, some patients had difficulty regularly getting to community sites, so therefore had difficulty meeting with the nurse for timely assessment of clinical measurements and review of action plans. The NPVNA attempted to remedy this by targeting community settings where transportation is most accessible (e.g., senior centers, shopping areas, faith communities, senior housing). Enrolling postepisod-
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ic home care patients presented some difficulty, as many of the patients were still homebound and unable to meet with the nurse in a community setting. Getting patients to agree and stay motivated to continue the home/episodic program into the community/postepisodic program was difficult at times if the initial outreach to the patient by the community nurse was delayed for any reason. All of these issues were addressed during the phase two or implementation year of the program, including more careful adherence to patient selection criteria and the development of better reporting tools to the patient primary care physician. Throughout the program planning, there was a necessary consideration of the older adults’ cognitive, literacy, cultural, and sensory needs, along with a balanced view of aging through a lens of strengths rather than deficits. Focus on strengths is especially important within an intervention where the goal is to increase self-efficacy. Nurses needed to consider each patient’s level of knowledge and confidence, plan their encounters according to sensory and literacy needs, and creatively find ways to encourage them to be actively involved in their health care. This coaching was meant to create active partnerships rather than passive or paternal relationships between nurses and patients (Institute Health Sciences Institute, 2008). Overall, the NPVNA-piloted CCM program became the impetus for retooling and restructuring a well-established home and community health provider, now better positioned to meet the needs of a changing patient population and health care delivery system.
References American Nurses Association. (2012). Faith community nursing scope and standards of practice (2nd ed.). Silver Spring, MD: Nursebooks.org. Brown, R. (2009). The promise of care coordination: Models that decrease hospitalizations and improve outcomes for medicare beneficiaries with chronic illnesses. Princeton, NJ: Mathematica Policy Research. Retrieved from http:// www.nyam.org/social-work-leadership-institute/docs/N3C-Promise-of-Care-Coordination. pdf Center for Disease Control and Prevention [CDC] and the Merck Company Foundation. (2007). The state of aging and health in America
Cooper and McCarter: Chronic Care Management 2007. Whitehouse Station, NJ: The Merck Company Foundation. Holman, H., & Lorig, K. (2004). Patient self-management: A key to effectiveness and efficiency in care of chronic disease. Public Health Reports, 119, 239–243. Improving Chronic Illness Care. (2011). The chronic care model. Retrieved from http://www.im provingchroniccare.org/index.php?p=The_ Chronic_Care_Model&s=2 Institute Health Sciences Institute. (2008). Chronic care professional (CCP) certification program manual. Chicago, IL: HealthSciences Institute. Institute of Medicine. (2008). Retooling for an aging America: Building the health care workforce. Washington, DC: National Academies Press. Lorig, K., Sobel, D., Gonzalez, V., & Minor, M. (2006). Living a healthy life with chronic conditions. Colorado: Bull Publishing Company. Lorig, K. R., Sobel, David., Stewart, A., Brown, Byron. W., Bandura, A., Ritter, P., et al.
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(1999). Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: A randomized trial. Medical Care, 37(1), 5–14. Matas, W. & Associates. (2010). The delineation of home health care: The Natural Evolution of a Healthy Industry (White Paper). Retrieved from http://www.wyattmatas.com/mimik/mi mik_uploads/white_papers/7/The%20Delinea tion%20of%20Home%20Healthcare%20Final %20041210.pdf Pennsylvania Homecare Association. (2010). Effective partners: Home health’s role in chronic care management (White Paper). Retrieved from http://www.pahomecare.org/pdf/White paper_Final.pdf Public Health Management Corporation. (2010). Community health database. Retrieved from http://www.chdbdata.org Westberg, Granger. E. (1990). The parish nurse: Providing a minister of health for your congregation. Minneapolis, MN: Augsburg Fortress.
