Community-based chronic disease care using a nurse led model

Introduction The Community-based Chronic Disease Management (CCDM) Clinic was created to deliver clinical care for patients with hypertension and diabetes type II in a setting of low resources and high need. This new model of care differs significantly from traditional models.

CCDM's model melds nurse-led teams with evidence-based clinical decision protocols. The clinic situated in food pantries in a mid-sized, impoverished, urban American city. CCDM's unique model is intentionally designed for a population lacking health insurance. It addresses barriers to care by eliminating high drug costs, excessive wait times, an appointment system, physician-led teams, and paper charts. Further, it leverages those resources that are community-based and patient-centered such as location, health care team leadership, and culturally attuned education.

Problem Statement For millions of uninsured Americans who have chronic disease, quality medical care is too expensive to access with any regularity. Episodic treatment of chronic disease can lead to high out-of-pocket expenses, haphazard treatment plans, and ultimately, increased morbidity.

Methods From October, 2007 to November, 2010, CCDM conducted a non-randomized prospective trial of the effect of a nurse-directed variation of the chronic care model in an uninsured population. The intervention included free education, medications, and laboratory investigations. Ad hoc consultation was available via phone, email, or in person.

Main Results For hypertensives treated for 6 months and 1 year, national benchmark goals were reached for 45% (30/67, p = 0.0004)and 65% (26/40, p = 0.0004), respectfully.

For diabetics treated for 6 months and 1 year, national benchmark goals were reached for 52% (11//21, p = 0.014) and 71% (12/17, p = 0.56), respectfully.

Conclusions The US is on the verge of a health care crisis with an aging population, a rising prevalence of chronic diseases, rising health care costs, and a relative shortage of access to primary care. Collectively, these forces will lead to both higher costs and greater amounts of human suffering – unless drastic changes are made to the current approach to the screening, diagnosis, and management of chronic disease.

Nurse-led care teams in community settings using evidence-based protocols for the screening and management of hypertension and diabetes can achieve outcomes at or better than national benchmarks at a fraction of the cost. The CCDM model may have implications for health service delivery in insured populations; especially in a health care climate of fiscal restraint.