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Face-to-face interventions help chronically ill
George is a 67-year-old man with diabetes, cardiac problems, and asthma who takes more than 10 medications. He is insulin- and oxygen-dependent, lives alone, and is illiterate.
When Vicki Manning, RN, began visiting George in his home as part of the LifeMasters Supported Self-Care Medicare demonstration program for dual-eligible beneficiaries with multiple chronic illnesses, it took several sessions to build up enough rapport for George to admit that he never learned to read and write.
Using pictures and drawings, Manning taught George about his illness and how to manage his medication and treatment regimen.
She drew symbols on his medicine bottles and on a chart to help him learn when to take each medication.
After six months of regular visits, George was able to take his medication regularly. He could monitor his blood pressure and heart rate and follow the parameters set by his physician to call in to the doctor's office when they reached a certain level.
He could check his blood sugar and give himself a regular dose of insulin as well as following a sliding scale to increase or decrease the dose based on blood sugar.
"I taught him how to access community services in his area and to visit a food pantry or call a hotline when he needs help paying his electric bill," says Manning, now team manager for LifeMasters' community services RN team.
George's story illustrates the effectiveness of face-to-face encounters in empowering people with multiple complex conditions to take charge of their own health care.
The majority of participants in the LifeMasters' demonstration project are managed by call center nurses, called clinical nurse consultants.
The community services RNs (CSRNs) are called in when the participants have a positive score on a frailty screening that identifies that they may be at risk, when they have had a recent fall, have been hospitalized, have vision or memory problems, take multiple medications, report an increased need for assistance in the home, or have multiple complex conditions.
The CSRNs also visit participants who do not have telephones and arrange for them to have free wireless telephone service that they can use for emergencies and telephonic intervention.
"If we get them stabilized, then they can be followed through the call center," Manning adds.
When participants are hospitalized, the CSRN visits them in the hospital and collaborates with the discharge planning team to ensure a smooth transition home. When participants are in a skilled nursing facility or assisted living center, the CSRNs visit the participants in the facility and partner with the staff to manage the care of the patients.
When a participant is referred to the community services RN team, a nurse makes a home visit to determine the person's needs and level of ability to self-manage his or her care.
"We look at medication adherence, functional ability, safety, housing, financial concerns, nutrition, transportation, and any care deficits and support systems. Our goal is to give participants the education and support they need to empower them to take an active role in their care," Manning says.
The dual-eligible Medicare and Medicaid population faces tremendous hurdles in learning to manage their own health care, Manning says.
Participants in the program are low income and often have problems paying for housing and food, let alone their medication or the healthful foods that are recommended for people with their chronic conditions, she says.
Many don't go to their physician appointments because they don't have a way to get there.
The nurses work as a team with social workers to identify community resources that can provide medication assistance, transportation to medical appointments, and help with housing or utilities. They assist the participants in identifying unnecessary expenses in their budgets, such as paying top rates for phone service when less expensive service is available.
"We work to meet their basic needs such as food and shelter before we tackle the medical issues. We are creative in helping participants find the resources they need. If we get food on the table, then perhaps they'll be open to monitoring their blood pressure," Manning says.
The nurses tailor the in-home visit to the participants' needs, their abilities, and their support system. Some require weekly visits; at a minimum, the nurses visit the participants at least every 30 days.
The team includes bilingual staff who speak English, Spanish, and Creole and who have access to a language line that provides interpreters for a variety of languages.
"Literacy is a huge hurdle in this population, and often, participants have a discomfort level in revealing this information to the staff," Manning says.
One way the nurses address the problem is to put pictures and symbols that the participant can relate to on their medication models so they will know what the medication is for and when to take it.
The nurses and social workers are assigned geographically by zip code and carry a caseload of 40 to 55 participants. They use wireless laptop computers to enter information on the LifeMasters system, which is shared by the call center nurses, giving both instant access to patient information.