Community case management of chronic disease is a cost-effective mechanism for providing intensive services for selected individuals within specific disease categories. This outreach program was implemented based upon findings that diabetes was the most common discharge primary or secondary diagnosis in a small community hospital serving a rural area. Individuals for case management were initially selected from hospital records of clients with 4 or more inpatient or ED visits within a 12 month period. Nursing case management services included: in-home assessment, frequent monitoring of blood pressure and blood sugar levels, foot checks, assistance with obtaining medications, and improved communication between the individual and physician. At the end of 18 months, outcomes included 62% reduction in ER visits, 58% reduction in inpatient visits, 54% decrease in LOS, and 44% decrease in patient charges. Major components identified by the outreach team as contributing to the success of the program include the caring relationship which is developed between nurse and client, access to the medication program and improved communication between physician and client.
Keywords: Case Management,
Presenting author's disclosure statement:
Organization/institution whose products or services will be discussed: None
I do not have any significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.