Nurse-led patient centered medical home effectiveness project

Cardiovascular disease (CVD) is a significant health problem for African American (AA) women. Based upon a qualitative study that explored the perceptions of African American women, 18-60 years of age diagnosed with CVD regarding barriers to care and factors related to achieving desired health outcomes, an intervention was designed. Registered nurse (RN) care managers, in two nurse practitioner led NCQA recognized Patient Centered Medical Home primary care clinics serving primarily public housing residents, provided individual coaching to patients diagnosed with diabetes, hypertension, hyperlipidemia and/or who were at risk for CVD because of a BMI over 30. The RN care managers assisted each patient enrolled in the study to develop self-management goals. The type of self-management goals selected by the participants and the impact on their BMI, systolic blood pressure, diastolic blood pressure, LDL and A1C will be presented. Six month post intervention data suggests decreases in BMI, blood pressure and A1C with self-care plans addressing caloric intake and nutrition, exercise, stress and smoking cessation. The final analysis will be completed by April 2013. Auditing the records of the low income women in this study provided a continuing context for understanding the complexity of their lives due to exposure to infectious diseases, violence, physical abuse, emotional abuse, substance abuse, loss of employment and homelessness. With all of this, the women have responding positively to selecting their own self-management goals and being supported with individualized coaching from RN Care Managers.