An overview of chronic disease management in the older adult.

1. Presented by Stephanie Thompson, RN
Chronic Disease
Management in the
Older Adult

2. 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)

3. 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.
Over 2 trillion is spent in the United States annually.
95% of this is direct patient medical care for older adults.
Cost of Chronic Disease Management
(Kapustin, 2010)

4. Is Chronic Disease Management
Relevant to Older Adults?
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.
YES !!!
(Healthy Aging, 2011)

5. My Intention
Chronic disease management interests
me because I’ve seen thru my own
nursing practice that patients and
families want help managing their
chronic illnesses. There is a real desire
from them to want to learn more.
My intention is to help clinicians learn
how to help patients manage their
chronic illnesses more efficiently,
effectively and achieve better
outcomes.
Education and
patient self-
empowerment
are the keys to
chronic
disease
management.

6. Assessment
Build Rapport
Empower Patient
Problem Solving
Identify Barriers
Collaboration
Effective Listening
Set goals
Evaluation
Self-management support is “the
systematic provision of education and
supportive interventions to increase
patients’ skills and confidence in
managing their health problems, including
regular assessment of progress and
problems, goal setting and problem
solving support.”
(Clark et al., 2009)
Chronic Disease and
Self-Management
Support Techniques

7. Chronic Disease
Management and the
Nursing Process
Steps of the
Nursing Process
Assessment
Diagnosis
Outcomes / Planning
Implementation Evaluat
ion
Clinicians can use each step of
the nursing process when
utilizing the support techniques
of patient self-management.
(ANA, 2014)

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

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

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

11. (Chronic Care and Disease Management, 2010)
(Suter, Hennessey, Harrison, et al., 2008)
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.
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

12. Application using the
Nursing Process
Care is
implemented
according to
the care plan
and
documented in
the patient’s
record.
 Promote change through
behavior modification
 Follow SMART Goals
 Keep logs
 Be the patient coach
 Teach about chronic illness
(ANA, 2014)

13. Application using the
Nursing Process Evaluation
status and the
effectiveness
of the nursing
care must be
continuously
evaluated, and
the care plan
modified as
needed.
 Evaluate logs and
journals
 Evaluate SMART goal
attainability
 Adjust SMART goals
where needed
(ANA, 2014)

14. Evidenced Based Practice
Sutter Care Coordination Program
Sutter Health Sacramento-Sierra Region
(Chronic Care and Disease Management, 2010)
 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.

15. Evidenced Based Practice
Self-Management Among
Socioeconomically Vulnerable Older Adults
(Clark et al., 2009)
 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.

16. 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)

17. Solutions for Clinicians
How to Help Your Patient Manage
Chronic Disease
 Use the Nursing Process Interventions
 Understand the Disease itself
 Promote Self-Management
 Reconcile Medications
 Care Coordination: PT, OT, and ST
 Increase Visits During Early Phase of New Disease
 Relate behavior changes to positive outcomes
 Establish Meaningful Relationship
Patient
confidence
yields
improved
outcomes
through a
more suitable
patient
decision
making
process.
(Suter, Hennessey, Harrison, et al., 2008)

18. 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?
.

19. 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.

20. 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.

21. 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