Patient Satisfaction, Empowerment, and Health and Disability Status Effects of a Disease Management-Health Promotion Nurse Intervention among Medicare Beneficiaries with Disabilities Bruce Friedman, Ph.D., University of Rochester Brenda R. Wamsley, Ph.D., West Virginia State University Dianne V. Liebel, Ph.D., R.N., University of Rochester Zabedah B. Saad, M.A., University of Wyoming Gerald M. Eggert, Ph.D., Monroe County Long Term Care Program, Inc./ACCESS Acknowledgments • Centers for Medicare and Medicaid Services, “A Randomized Controlled Trial of Primary and Consumer-Directed Care for People with Chronic Illnesses,” CMS # 95-C-90467, Gerald M. Eggert, P.I.; Project Officers: Carolyn M. Rimes, Tamara Jackson-Douglas, and Don Sherwood. Background • In recent decades considerable effort has been devoted to improving patient health and disability status as well as patient satisfaction of chronically ill individuals. • Part of this effort has consisted of approaches that have focused on empowering patients and improving their self-efficacy. • It is essential that interventions be developed for Medicare beneficiaries with disabilities. • The present study is important because it reports on one of the first disease management-health promotion interventions for this population. Demonstration Summary • 2 sites (N = 1605) – New York State – 8 counties (N = 1082) – West Virginia/Ohio – 11 counties (N = 523) • First participant enrolled in July 1998 • Last participant finished in June 2002 • Randomized controlled trial with 3 intervention groups & a control group • Each participant was eligible for 24 months Eligibility Criteria • Be living in the community • Need or receive help for: – At least 2 Activities of Daily Living (ADL), or – At least 3 Instrumental ADLs • Have had recent significant healthcare use: – Hospital, nursing home, or Medicare home care during the past year, or – At least two emergency room visits during the past 6 months • Have a participating primary care physician 3 Models of Consumer-Directed Care • Disease Management-Health Promotion Nurse (Nurse) • Voucher • Combination (Nurse plus Voucher) Background • The Nurse Group intervention derived from the logic that empowering older adults with chronic illness to better manage their own health and interact more effectively with health practitioners would result in improved satisfaction as well as in better health and disability outcomes. • Previous research on enhancing patient empowerment and self-efficacy (Bandura, 1997) and on expanding patient involvement in their own care (Kaplan, Greenfield, & Ware, 1989) had found improvements in patient health behaviors as well as in health and functional status. Nurse Intervention • Monthly Nurse home visits to teach and coach disease self-management – Consumer Self-Care Strategies – Healthwise for Life • PRECEDE health education planning model for health behavior change strategies • Special Medicare payment of $60 per visit for up to 4 physician-patient-caregiver-Nurse office conferences Nurse Intervention • Differs from most disease management studies since they usually concentrate on a single chronic illness • The Nurses did not provide most typical “hands-on” nursing care such as dressing changes and intravenous therapy care Research Objective • To report the impact of a primary careaffiliated disease self-management-health promotion nurse intervention for Medicare beneficiaries with disabilities and recent significant health services use on: – Patient and informal caregiver satisfaction – Patient empowerment – Patient health and disability status Hypotheses 1. Satisfaction with the intervention by the Nurse group patients and their informal caregivers will increase over time. 2. The Nurse group patients will be more empowered and have greater self-efficacy at the end of the study than will the Control group beneficiaries. 3. Health and disability status will be better at the end of the study for the Nurse group than for the Control group. Data Collection • Satisfaction data to test Hypothesis 1 were collected from the patients and their primary informal caregivers in the Nurse group (but not in the Control group) at 10 and 20 months after the intervention phase started. • Data on patient health and disability status and other characteristics to test Hypotheses 2 and 3 were obtained from a baseline interview and at 22 months postbaseline. Dependent Variables • Patient and caregiver satisfaction – Patient: 20 questions comprising 7 domains – Caregiver: 21 questions comprising 8 domains – Response for each question is a 5-point Likert scale from 1 (not at all satisfied) to 5 (completely satisfied) • Patient empowerment – General self-efficacy (Rodin & McAvay, 1992), – Health self-efficacy (Rodin & McAvay, 1992), – The 3 Multidimensional Health Locus of Control subscales (Wallston, Wallston, & DeVellis, 1978) – Chance, Internal, Powerful Others Dependent Variables • Patient health and disability status – Self-rated health status – SF-36 Health Survey (Ware, et al., 1993) • Physical Component Summary (PCS) score • Mental Component Summary (MCS) score – Number of ADL dependencies (Shaughnessy, Crisler, & Schlenker, 1997) – Number of IADL dependencies (Shaughnessy, Crisler, & Schlenker, 1997) Independent Variables in Ordered Logit & Linear Regression Models • The 3 intervention groups • Site • Baseline value of the dependent variable being estimated • Age • Gender • Baseline value for the 8 variables that differed at p<.10 across the 3 intervention groups and the Control group at baseline: o Medigap insurance (yes/no) o Private long term care insurance (yes/no) o SF-36 Mental Component Summary score o Cognitive Performance Scale score o Hypertension (yes/no) o Prior nursing home use (yes/no) o Number of ADL dependencies o Number of IADL dependencies Statistical Analysis • To compare satisfaction scores at 10 months and 20 months: – Generalized linear models for repeated measures • To evaluate the effect of the Nurse intervention at 22 months on empowerment and health and disability status: – Ordered logit – Linear regression analysis Beneficiary Baseline Characteristics: Nurse and Control Groups (N=766) • • • • • Mean age = 77.4 years (range: 23-102) Age 85+ = 27% Male = 31% Minorities = 4% Mean number of: – Chronic conditions = 4.4 (SD=2.2) – ADL dependencies = 2.3 (SD=1.9) – IADL dependencies = 3.5 (SD=1.8) Nurse Intervention • 11 nurses provided services to the 802 patients in the Nurse and Combination groups • Average caseload during the Demonstration’s “steady-state” phase = ~ 65 patients per nurse • The 382 patients in the Nurse group received a mean of: – 19.03 Nurse visits (SD=12.44; range: 0-96) in all settings (home, hospital, nursing home, MD office) – 0.98 Nurse visits per month (SD=0.56) – 3.24 goals developed with the Nurse (SD=3.78) (range: 0-19) during the time s/he was enrolled Results: Improvement in Patient Satisfaction between 10 and 20 Months Postbaseline Domains n 10 20 Month Mean Month Mean t p Improved Health 183 3.45 3.61 2.24 .03** Satisfaction with Nurse Tool 179 3.38 3.60 2.28 .02** Satisfaction with Nurse Relationship 183 4.21 4.35 2.73 .01** Satisfaction with Primary Care Provider/Health Provider 178 3.35 3.56 2.32 .02** General Satisfaction with Nurse Intervention 183 3.72 4.00 3.90 <.01*** Improved Relationship with Family 167 3.05 3.25 1.56 .12 Satisfaction with Primary Care Partnership Meeting 136a 3.35 3.73 3.24 <.01*** Results: Improvement in Caregiver Satisfaction between 10 and 20 Months Postbaseline n 10 Month Mean 20 Month Mean t p Improved Health 125 2.96 2.99 1.19 .24 Satisfaction with Nurse Tool 116 3.11 3.22 1.10 .28 Satisfaction with Nurse Relationship 119 3.64 3.77 1.87 .06* Satisfaction with Primary Care Provider/Health Provider 119 3.08 3.07 -0.14 .89 General Satisfaction with Nurse Intervention 121 3.28 3.40 1.55 .12 Improved Relationship with Family 110 2.65 2.72 0.70 .49 Satisfaction with Primary Care Partnership Meeting 26a 3.19 3.31 0.62 .54 Satisfaction with Nurse Help to Reduce Caregiver Stress 116 2.64 2.85 2.17 .03** Domains 22-Month Adjusted Patient Empowerment Results for the Nurse Group Variable Dependent Variable Nurse Group Variable Results B SE B z/t p Health Self-Efficacy -0.01 0.27 -0.05 .96 Self-Efficacy Scale -0.25 0.22 -1.13 .26 Internal Health Locus of Control Scale -0.37 0.35 -1.07 .29 Powerful Others Health Locus of Control Scale -0.26 0.39 -0.67 .50 Chance Health Locus of Control Scale -0.33 0.42 -0.78 .43 22-Month Adjusted Health and Functional Status Results for the Nurse Group Variable Dependent Variable Nurse Group Variable Results B SE B z/t p Self-Rated Health Status (1-5) 0.06 0.18 0.33 .74 SF-36 Physical Component Summary (PCS) Score (0-100) 0.14 0.77 0.17 .86 SF-36 Mental Component Summary (MCS) Score (0-100) 0.81 0.85 0.96 .34 Activities of Daily Living – Dependence (0-6) -0.25 0.12 -2.07 .04** Instrumental Activities of Daily Living – Dependence (0-6) -0.16 0.12 -1.33 .18 Discussion: Hypothesis 1 • Our hypothesis was partially supported. – Patient satisfaction - statistically significant improvement between 10 and 20 months for 6 of the 7 domains. – Caregiver satisfaction - significant improvement for 2 of the 8 domains. • A nurse home visiting review reported better patient satisfaction for the intervention group in 4 studies (4 other studies had no significant intervention effect) (Marek & Baker, 2006). • A systematic review reported higher patient satisfaction for the intervention group for 12 of 17 disease management programs (Ofman, et al., 2004). Discussion: Hypothesis 2 • Our hypothesis, that the Nurse group patients would be more empowered and have greater self-efficacy at the end of the study than would the Control group, was not verified. • Several studies have found significantly higher empowerment scores for empowerment interventions for orthopedic, diabetes, prostate cancer, and end stage renal disease patients (Tsay & Hung, 2004). • A recent review identified 15 articles that have evaluated the effect on patients of empowermentbased interventions (Aujoulat, d’Hoore, & Deccache, 2007). However, only 2 of these studies had a mean age of study participants as high as age 65. Discussion: Hypothesis 2 Possible reasons why our empowerment results differed from the positive findings often found: 1. Our nurses might not have been sufficiently trained in patient empowerment, health behavior change, and chronic disease self-management education. 2. Our patients may have received too little formal education, had too much disease burden, and/or been too disabled as a result of advanced age to become more empowered. • A review by Auerbach (2001) reports that less education, more serious or severe illness, and older age are associated with increased willingness to relinquish control to others. Discussion: Hypothesis 2 • Of 22 studies that examined the relationship between age and the desire for medical decisionmaking, 17 reported a significant association. Each of these 17 found that older persons were less interested in having an active role in medical decision-making (Say, Murtagh, & Thomsom, 2006). 3. Our measures may not have been appropriate. 4. The patients may have been already sufficiently empowered so that it would not have been possible to increase this or selfefficacy above that of the Control group. Discussion: Hypothesis 3 • Our hypothesis, that health and disability status would be better at the end of the study for the Nurse patients than for the Control group, was partially supported. • Our absence of positive findings for the SF-36 PCS and MCS scores is similar to the results of 8 nurse home visiting studies (Marek & Baker, 2006). • A review of disease management studies for 11 chronic illnesses reported that the proportion of statistically significant comparisons in favor of the intervention group was low (Ofman, et al., 2004): – 7 of 24 (29%) studies that measured morbidity – 7 of 35 (20%) that assessed physical functioning – 5 of 31 (16%) that examined health status/life quality Limitations • Generalizability to other geographic areas • Representativeness of Medicare beneficiaries with 2+ ADLs or 3+ IADLs that experienced recent significant health services utilization • Intervention intensity – It may not have been intense enough since it relied primarily on patient self-management and included little “hands-on” nursing. Policy Implications • This study provides evidence supporting the premise that a multi-component, primary care affiliated health promotion/disease selfmanagement intervention holds the potential to delay functional decline among beneficiaries with ADL dependence. • Second, this study shows that health promotion /disease self-management interventions are well received by beneficiaries. Conclusion • This intervention improved patient satisfaction and resulted in less ADL dependence as compared with a Control Group at the end of a 22 month treatment period. • Research is needed to confirm and hopefully build on our findings.