Health status and intensity of need for nursing care outcomes in a socially vulnerable population

Background: Populations with Type 2 diabetes experience many challenges which are especially burdensome for those without health insurance or adequate access to care. The overall purpose of this study was to examine outcomes in a vulnerable population with Type 2 diabetes who received a public health nurse care coordination intervention (case management) Home visitation was the primary modality. Methods: A longitudinal, descriptive correlational design was used to examine outcomes of the care coordination intervention. Major outcomes studied were self-reported health status (SRHS), intensity of need for nursing care, diabetes empowerment and depression. The sample was purposive (n=27). The intervention goal was improved self-management of diabetes and health promoting lifestyle behaviors. Results: 43% of the sample was Spanish-speaking.; 67% female and the mean age 53 years. Mean intensity of need scores at admission were moderate (30) and decreased over time with higher dose effects. The Respiratory/Circulatory intensity parameter had the highest mean score at admission. Mean admission SRHS total scores = 486 (177 SD); mean Diabetes Empowerment scores = 4.3 (SD .61); mean PHQ-9 scores = 8.4 (6.8 SD). Lessons Learned: Care coordination for vulnerable populations is challenging but positive change in self- management can be made with intensive self-management support using tailored action plans, higher doses of PHN care coordination and adequate resources. Conclusions: As implementation of the Affordable Care Act continues, care coordination is an effective intervention strategy for health improvement and enhancing client self- efficacy for very vulnerable populations but may take higher doses of care.