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Nancy L. Rothman, MSN, EdD, RNIndependence Foundation Professor of Urban Community
NursingDept . Of Nursing, CHP&SW, Temple University
Cheryl Peterson, MSN, RNDirector Department of Nursing Practice and Policy
American Nurses Association Paula DeCola, MSC, RN
Senior Director, External Medical AffairsPfizer, Inc.
Nancy De Leon Link, MGAChief Operating Officer
National Nursing Centers Consortium
Presenter DisclosuresThe following personal financial relationships with
commercial interests relevant to this presentation existed during the past 12 months:
No relationships to disclose
Initiative Description Evaluating nurse-led
primary care in NCQA recognized Patient-Centered Medical Homes with CRNP and RN Care Manager teams
In two primary care clinics in public housing
African American women 18-60 years of age diagnosed with diabetes, hypertension, hyperlipidemina or at risk due to a BMI > 30; n-116
Public Health Management Corporation Nursing NetworkPHMC Health Connection
Rising Sun Health Center
Intervention Development IRB approval first for initial
focus groups and then for intervention study and post intervention focus groups
Focus groups (8-10 patients) at two NCQA recognized nurse-led primary care clinics conducted to investigate how to improve health outcomes of African American Women who are diagnosed or at risk for cardiovascular disease
Intervention designed based upon initial focus groups – individual coaching by RN Care Managers
Analyzed process and outcome measures
Focus groups (8-10) at same two NCQA recognized nurse-led primary care clinics to measure satisfaction with the intervention
Pre-intervention patient focus groups:Expressed confusion and concern about medication use,
diet and self management of diabetes. “I am on two medications for my blood pressure and three for
my diabetes. It is back and forth, back and forth trying to get the results they want.”
“You have to stay stable; you have to eat breakfast on time and you have to eat between meals.”
Stressed difficulty adopting a diet that would allow them to lose weight or maintain a better blood sugar level. “Sometimes I get nervous, like when I don’t eat…I realize my
sugar is low…it can go under 70 , that’s when I feel it.”
Indicated family support was important to their efforts to take medication, eat better and try to be physically active. “I love junk food, but my husband does not let me eat it.” “My granddaughter or daughter will call me and ask, Nana did
you take your medicine?”
Identified the areas of self-care management with which they needed assistance to improve their health outcomes. “It is easy for them to tell you what you need to do, but hard
for you to do it.” “Eating right, exercising , reducing stress…” “Some of the pills make you nauseous and/or sleepy.”
Intervention:RN Care Managers coached patients on their selected self–management goals
Reducing stressExerciseNutrition
Statistically significant increase in self-management goals related to stress, exercise and nutrition (p=>.0001)
No significant increase in self-management goals related to smoking.
Statistically significant improvement69/116 kept 6 mo. face
to face appointmentLDL (p=.002)Number of cigarettes
smoked (p=<.0001)
80/116 kept 12 mo. face to face appointmentLDL (p=.03)Number of cigarettes
smoked (p=.03)Above consistent with self- management of stress,nutrition and exercise.
38/116 kept 18 mo. face to face appointmentSystolic blood pressure
(p=.001)Diastolic blood pressure
(p=.001)A longer term impact,consistent with self-management of stress,nutrition and exercise.
Improvement in LDL and number
of cigarettes smoked notsignificant.
Clinically significant outcome measures baseline to 12 and 18 mos.
Body Mass Index
Hemoglobin A1C
39 % had reduced BMI at 12 months and
60% at 18 months
47% had reduced A1C at 12 months and
25% at 18 months
SF 12 Outcome Measures:Pre- vs. Post-interventionMedical Outcomes Short Form measures perceptions of the
patient’s own health to include: general health, physical functioning, bodily pain, vitality, social functioning, role limitation physical, role limitation emotional, physical health and mental health.
Subjects had statistically significant positive changes in bodily pain (p<.0001), role limitation emotional (p<.0001), social functioning (p=.003)and mental health (p=.0004).
Consistent with statistically significant increase in self-management goals related to stress and RN Care Managers reporting self-management goals relating to stress were primary prior to patients being able to think about other goals.
Post-intervention patient focus groups:Expressed better understanding of medication use, diet and
self management of diabetes, hypertensions and lipid levels because RN Care Manager took time with them and helped patients to set monthly goals. “Because I didn’t have a clue what was going on with being a
diabetic and you really took time out to help me.” “You helped me out with my smoking. I am down to half a pack
per day.”
Meeting one on one with RN Care Managers provided very personal individualized assistance in taking small steps to improve their health over time. “My cholesterol is really good. Like I was shocked when my
heart doctor told me it was perfect because it was sky high.” “Yeah, me with the junk food and I stopped. I drink water and I
eat alot of vegetables and fruit.”
Both parents and children supported patients efforts to take medication, reduce their stress, eat better, decrease or stop smoking and to be more physically active. “All of my family stopped smoking.” My mother started buying more healthy stuff for the house.”
RN Care Managers and clinic staff are encouraging and caring, when you have insurance and when you do not. “I love this clinic and program, because a few months ago my
insurance ran out. No one would provide my medicine but here the nurse practitioner went to the back and gave me some. ”
“The RN Care Manager is very dedicated and sincere. I feel it is more than just a program to her.”
ChallengesAfrican American Women in the study were
residents of public housing or homeless
Uninsured or had Medicaid insurance
Auditing the records of the low income women in this study provides a continuing context for understanding the complexity of their lives, primarily related to exposure to infectious diseases (STDS and TB), violence, physical abuse, emotional abuse, substance abuse, loss of employment and homelessness.
Success and Future Direction In spite of the complexity of their lives, the women responded
positively to selecting their own self-management goals and being supported with individualized coaching from RN Care Managers.
Public Health Management Corporation, owner of these two nurse-led NCQA recognized PCMHs, is committed to continue to provide support for patients to meet their selected self-management goals.
This study provides evidence of the need for a longitudinal study with a larger sample size over at least three years to evaluate the impact of this intervention on achieving and maintaining outcome goals and documenting the cost per patient for the intervention.
Acknowledgements Project was conducted in collaboration with: the National Nursing Centers Consortium,
PublicHealth Management Corporation, Temple
Universityand the American Nurses Association and
Pfizer, Inc.who also in part provided financial support forthe study.
Contact information Nancy L. Rothman, EdD, RN
Independence Foundation Professor of Urban Community Nursing
Temple University
