Improving Self-Management Practices Among Patients With Chronic Conditions: “We’ve Got an App for That!”

Friday, 28 July 2017: 1:30 PM

Shannon Cronin Patel, DNP, BSN
Rutgers University, Camden, NJ AtlantiCare Regional Medical Center(ARMC), Pomona, NJ, Galloway, NJ, USA
Pamela Walch, MSN, BSW
Quality Management, Atlanticare Regional Medical Center - A Member of Geisinger Health Systems, Pomona, NJ, USA

Abstract Summary

The Nurse Developed Manage ME model was created to address the gaps that existed within patient education delivery models for patients living with chronic conditions. This self-management education deliver model has been foundational to creation of the innovative Manage ME toolkits and Mobile ME smart device applications. These self- management focused patient education “toolkits” have enabled all patient educators, including busy clinical nurses, to provide successful, standardized, patient-centric, self management education in an effective and efficient manner that crosses all transitions in care. The use of these Manage ME toolkits and Mobile MEsmart device apps. have improved self-management related behaviors of patients with chronic conditions, resulting in improved patient outcomes.

According to data collected through the Centers for Medicare & Medicaid (CMS), one of the leading causes of “avoidable” hospital readmissions for patients with chronic conditions have had a causal relationship to ineffective self management practices commonly demonstrated by this patient population. Multiple gaps have existed within the current self management education delivery models. The "Manage ME" toolkits have enabled clinical nurses to provide focused self management education to this patient population in an efficient and effective manner leading to improved patient outcomes and decreased readmission rates.

Strategy and Implementation:
The Manage ME education delivery model has been used to create a suite of 5 self- management toolkits and smart device applications for the following conditions: heart failure, diabetes, COPD, as well as tobacco cessation management and wellness support. The pioneer toolkit that was created for heart failure self-management education and this toolkit and smart device app. will serve as example for this abstract.

After a successful pilot study, the WOW ME 2000 the WOW ME 2000 (Weigh, Output & intake monitoring, Walk and be active, Medication adherence, Evaluation of symptoms, 2000 mg or less of sodium and fluids daily) was implemented throughout a multisite health care system. This innovative toolkit was created based in accordance with current guideline recommendations and regulatory standards of care. This toolkit enabled nurses of all experience levels to provide self management education in a standardized, systematic, progressive, manner that incorporated the 'Teach Back’ method after each information segment to ensure that frequent knowledge assessments dictate the progression of education at the appropriate speed for each individual patient. The WOW ME 2000 self-management tool is patient centric and devised to span the continuum so that nurses/patient educators are not pressured to complete all education during a brief hospital stay.


A 6 month pilot program that utilized the WOW ME 2000 Self Management Toolkit to educate all inpatient heart failure patients prior to their discharge from the acute care setting was conducted during the creation/developmental phase of this innovative practice intervention. This pilot program resulted in decreased heart failure readmissions from 26% to 17% this use of the heart failure self-management education toolkit continued to yield similar results across the health care continuum. There are several studies in progress that officially and unofficially include this self-management toolkit. The results from these studies prompted the creation of the WOW ME 2000 smart phone app. Since 2010 several organizations have successfully implemented the WOW ME 2000 toolkit and/or app. into their standard of care with similar successes.

Based upon the success of the heart failure toolkit, a smart device app. was developed. This self-management focused, interactive smart device app. was created to compliment the toolkit to provide ongoing guidance, support, communication and of heart failure patient. This smart phone application was accepted by Apple and released as a free app. in the Apple App. store in 2012. The app was also created for androids and was released on Google Play in 2011. Since its release, the app has been updated and the new version was released in 2015.

There has been one study of the WOW ME 2000 smart device app. and the data was published in the November 2014 issue of the Remington Report. A current study being conducted is studying heart failure patients while they utilize the WOW ME 2000 app for 30 days. This practice improvement, capstone project will refute or support the hypothesis that daily use of the WOW ME 2000 app. can increase knowledge of and adherence to successful self management practices.

The positive outcomes that our patients have experienced throughout our healthcare system has been successfully replicated at number of healthcare organizations including: acute care organizations, provider offices, rehab centers, heart failure and diabetes management clinics. Since their release, the WOW ME 2000 heart failure app. and the MEET ME @ 7 diabetes self- management app. have both been downloaded in over 16 different countries around the world.

Implications for Practice:
This nurse led innovation has significantly improved upon the provision of self management education for patients with heart failure and/or Diabetes. Through the provision of focused, standardized, patient centered education, nurses have been able to facilitate improved outcomes and decreased acute care admissions for patients with these chronic conditions.

Based upon the overwhelming success of our heart failure and diabetes self management educational toolkits and smart device apps. the nursing leadership team at our organization has approved the creation and implementation of additional toolkits for COPD, smoking cessation and wellness promotion. These toolkits and smart device apps. are currently in development. The additional toolkits will be initiated throughout our healthcare organization as soon as they are completed and vetted throughout the organization’s leadership team.