Abstract

We evaluated the quality of care provided to older patients with complex needs in a dual-eligible, community-based Medicare Special Needs Plan that used a nurse care manager model. Care provided by physicians was substantially supplemented by nurse care managers, as measured by Assessing Care of Vulnerable Elders quality indicators. We describe selected nurse care manager activities for six geriatric conditions (falls, dementia, depression, nutrition, urinary incontinence, and end-of-life care) during provision of patient care coordination and management for patients in the highest decile of clinical complexity. We identify areas of high nurse performance (i.e., falls screening, functional assessment, behavioral interventions for dementia problems, advance care planning) and areas of potential missed opportunities (i.e., follow up for new memory problems, targeted dementia counseling, nutrition, and behavioral approaches to urinary incontinence). Increasing the collaborative interaction between nurses providing care in this model and physicians has the potential to enhance nurses' contributions to primary care for vulnerable older adults.

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Authors

Roth CP, Ganz DA, Nickles L, Martin D, Beckman R, Wenger NS

Institution

RAND Health, Santa Monica, CA 90407, USA. roth@rand.org

Source

Journal of gerontological nursing 38:7 2012 Jul pg 44-54

MeSH

Accidental Falls
Dementia
Depression
Eligibility Determination
Health Services Needs and Demand
Humans
Malnutrition
Medicare
Nursing
Patient Care Planning
Quality of Health Care
Terminal Care
United States
Urinary Incontinence

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

22833891