Implementing a Nurse-Led Community Care Team in Primary Care

Purpose:

Background/Significance: Coordinating patient-centered care in primary care/Health Care Home (HCH) settings requires not only primary care redesign but also realignment between health care delivery systems and community service providers. Few structure and processes exist for collaboration between primary care and community services beyond minimally effective referrals.  Developing and implementing community care teams are integral to delivery of comprehensive, well-coordinated care that supports patient self-management of multiple chronic health conditions. Our preliminary work developing a Community Care Team (CCT) resulted in improved outcomes for patients by leveraging three proven approaches that support successful self-management: nurse care coordination, community service use, and the Wraparound process.

The Wraparound Process is a community-focused, strengths-based approach that was originally developed to initiate and coordinate the use of comprehensive community-based services as an alternative to institutionalization of high risk adolescents. “Wraparound” has become a common term for flexible, comprehensive services intended to keep children in the community.¹ Since the 1980’s, Wraparound has demonstrated positive outcomes for children and adults with mental health problems.^2-5 The CCT project incorporates Wraparound principles to achieve similar effects for adults with multiple chronic health conditions.

Initial nurse care coordination efforts report decreased use of costly health services, lower health care expenses, and improved self-management behaviors.^6-10 However, nurse care coordination is a new and developing nursing practice often limited by minimal integration with primary care, community services, and by poorly coordinated care transitions.^11,12 The CCT extends this evolving nursing role by providing needed programmatic structure and processes to link primary care with community services - thus enhancing the impact of nurse care coordination on patient outcomes.

Purpose: the purpose of this project is to implement and evaluate a nurse-led Community Care Team as an intensive intervention linking patients/families, primary care and community services to enhance care coordination and self-management support for patients with multiple chronic health conditions. 

Methods:

 Design: naturalistic, descriptive, implementation project. The Chronic Care Model is the framework for the CCT project.

 Sample/Setting:  The population of interest is older adult patients with multiple chronic health conditions experiencing difficulties in managing their health conditions and at risk for use of expensive health services.  All patient subjects must be receiving nurse care coordination through the primary care/HCH. A special focus is on providing the CCT program to “dual-eligible” individuals who qualify for both Medicaid and Medicare. The setting is two health care home/primary care practices in the upper Midwest of the United States.

Procedures:  The CCT program implementation builds on a community care team pilot project funded by the Minnesota Department of Health.  The CCT program implementation involves identifying and partnering with community institutions including 2 medical centers (each with certified health care homes) and the county health department, an intercultural assistance program, and senior services (Elder Network). The partnering organizations are also members of a community healthcare collaborative, a well-functioning and trusted group of community leaders that coordinate and integrate community-based efforts among the organizations. This collaborative group serves as the governing body for the CCT project.

CCT Intervention: The CCT program is a community-based interdisciplinary care team to support patient-centered primary care within the HCH. The CCT is holistic and person-centered, focused on integrating clinical and community services to address patients’ priority concerns.  The CCT intervention is an intensive 12 week program that includes 2 meetings with each patient and involves: action and crisis prevention planning, strengthening an informal circle of support, and follow-up self-management support by the CCT team members.

Measurement: The project goal is to provide patient-centered care that is effective, efficient and timely as measured by: 1) evaluation of patient-focused intervention outcomes and 2) evaluation of community-focused intervention outcomes, 3) Implementation outcomes.

 Patient-focused Intervention Outcomes.

Outcomes measures and instruments include: 1) Patient Assessment of Chronic Illness Care (PACIC), 2) Physical and Mental Health (Global Health Scale), 3) Resilience (CD-RISC-10), 4) Confidence to manage chronic health conditions (Self-Efficacy Scale), 5) Knowledge, Behavior, and Status regarding priority problems (Omaha System); all measured at baseline, 3 and 6 months.

 Community-focused Intervention Outcomes. Measures include: 1) Community services recommended by CCT, 2) Use of recommended community services, 3) Use of expensive health services (hospitalizations, emergency department visits, nursing home admissions) measured at baseline, 3 and 6 months.

 Implementation Outcomes: Measures include: 1) Reach – extent of CCT participation, proportion of the target population recruited and participated, 2) Effectiveness – effects of the intervention – intervention outcome measures - perceptions/ satisfaction of patients, caregivers, NCCs, CHWs via semi-structured interviews with a sample of participating staff, 3) Adoption – proportion of NCCs who refer and attend CCT for eligible patients; barriers for not referring or not using CCT; feasibility to adopt the CCT in real-world settings, 4) Implementation – CCT is delivered as intended; consistent across settings; adaptations needed/made, 5) Maintenance – extent to which the CCT becomes routine within HCHs; mechanisms in place to assess outcomes on an on-going basis; long-term attrition; training materials measured semi-annually. 

 Analysis: Descriptive statistics will be used to summarize sample characteristics and describe the data. Continuous features will be summarized with means, standard deviations, medians, and ranges; categorical features will be summarized using frequency counts and percentages. Baseline demographic and clinical characteristics and changes from baseline to 3 and 6 months between participants will be compared.  

Results:

Preliminary results of the implementation process as well as initial patient, community and implementation outcomes will be presented. 

Conclusion:

Nurses are experienced with providing care in a limited role within a medical model, but they have minimal experience with new care models, and much less experience interacting with community services. Indeed, the American Academy of Ambulatory Care Nursing has only recently identified nurse roles and competencies for care coordination and transition management. The inclusion of nurse care coordinators as the pivotal link between primary care and community care is an effective approach to extend the nursing role to full scope of practice within primary care settings. Nurse care coordinator involvement with the CCT program using a strengths-based Wraparound approach significantly extends nurse care coordinators’ understanding and provision of patient-centered care to enhance patient self-management. This project is consistent with the vision of the IOM Report, The Future of Nursing: Leading Change, Advancing Health,¹³ which emphasizes participation of nurses practicing at full scope of their license as a critical component for transforming health care. Results of this project will advance our ability to extend strengths-based nurse care coordination services through partnerships with existing community services.