Patient Satisfaction, Empowerment, and
Health and Disability Status Effects of a
Disease Management-Health Promotion
Nurse Intervention among Medicare
Beneficiaries with Disabilities
Bruce Friedman, Ph.D., University of Rochester
Brenda R. Wamsley, Ph.D., West Virginia State University
Dianne V. Liebel, Ph.D., R.N., University of Rochester
Zabedah B. Saad, M.A., University of Wyoming
Gerald M. Eggert, Ph.D., Monroe County
Long Term Care Program, Inc./ACCESS
Acknowledgments
• Centers for Medicare and Medicaid Services,
“A Randomized Controlled Trial of Primary
and Consumer-Directed Care for People with
Chronic Illnesses,” CMS # 95-C-90467, Gerald
M. Eggert, P.I.; Project Officers: Carolyn M.
Rimes, Tamara Jackson-Douglas, and Don
Sherwood.
Background
• In recent decades considerable effort has been devoted
to improving patient health and disability status as well
as patient satisfaction of chronically ill individuals.
• Part of this effort has consisted of approaches that
have focused on empowering patients and improving
their self-efficacy.
• It is essential that interventions be developed for
Medicare beneficiaries with disabilities.
• The present study is important because it reports on
one of the first disease management-health promotion
interventions for this population.
Demonstration Summary
• 2 sites (N = 1605)
– New York State – 8 counties (N = 1082)
– West Virginia/Ohio – 11 counties (N = 523)
• First participant enrolled in July 1998
• Last participant finished in June 2002
• Randomized controlled trial with 3
intervention groups & a control group
• Each participant was eligible for 24 months
Eligibility Criteria
• Be living in the community
• Need or receive help for:
– At least 2 Activities of Daily Living (ADL), or
– At least 3 Instrumental ADLs
• Have had recent significant healthcare use:
– Hospital, nursing home, or Medicare home care
during the past year, or
– At least two emergency room visits during the past
6 months
• Have a participating primary care physician
3 Models of
Consumer-Directed Care
• Disease Management-Health Promotion
Nurse (Nurse)
• Voucher
• Combination (Nurse plus Voucher)
Background
• The Nurse Group intervention derived from the logic
that empowering older adults with chronic illness to
better manage their own health and interact more
effectively with health practitioners would result in
improved satisfaction as well as in better health and
disability outcomes.
• Previous research on enhancing patient empowerment
and self-efficacy (Bandura, 1997) and on expanding
patient involvement in their own care (Kaplan,
Greenfield, & Ware, 1989) had found improvements
in patient health behaviors as well as in health and
functional status.
Nurse Intervention
• Monthly Nurse home visits to teach and
coach disease self-management
– Consumer Self-Care Strategies
– Healthwise for Life
• PRECEDE health education planning model
for health behavior change strategies
• Special Medicare payment of $60 per visit
for up to 4 physician-patient-caregiver-Nurse
office conferences
Nurse Intervention
• Differs from most disease management studies
since they usually concentrate on a single
chronic illness
• The Nurses did not provide most typical
“hands-on” nursing care such as dressing
changes and intravenous therapy care
Research Objective
• To report the impact of a primary careaffiliated disease self-management-health
promotion nurse intervention for Medicare
beneficiaries with disabilities and recent
significant health services use on:
– Patient and informal caregiver satisfaction
– Patient empowerment
– Patient health and disability status
Hypotheses
1. Satisfaction with the intervention by the Nurse
group patients and their informal caregivers
will increase over time.
2. The Nurse group patients will be more
empowered and have greater self-efficacy at
the end of the study than will the Control
group beneficiaries.
3. Health and disability status will be better at
the end of the study for the Nurse group than
for the Control group.
Data Collection
• Satisfaction data to test Hypothesis 1 were
collected from the patients and their primary
informal caregivers in the Nurse group (but not
in the Control group) at 10 and 20 months after
the intervention phase started.
• Data on patient health and disability status and
other characteristics to test Hypotheses 2 and 3
were obtained from a baseline interview and at
22 months postbaseline.
Dependent Variables
• Patient and caregiver satisfaction
– Patient: 20 questions comprising 7 domains
– Caregiver: 21 questions comprising 8 domains
– Response for each question is a 5-point Likert scale
from 1 (not at all satisfied) to 5 (completely satisfied)
• Patient empowerment
– General self-efficacy (Rodin & McAvay, 1992),
– Health self-efficacy (Rodin & McAvay, 1992),
– The 3 Multidimensional Health Locus of Control
subscales (Wallston, Wallston, & DeVellis, 1978) –
Chance, Internal, Powerful Others
Dependent Variables
• Patient health and disability status
– Self-rated health status
– SF-36 Health Survey (Ware, et al., 1993)
• Physical Component Summary (PCS) score
• Mental Component Summary (MCS) score
– Number of ADL dependencies (Shaughnessy,
Crisler, & Schlenker, 1997)
– Number of IADL dependencies (Shaughnessy,
Crisler, & Schlenker, 1997)
Independent Variables in
Ordered Logit & Linear Regression Models
• The 3 intervention groups
• Site
• Baseline value of the
dependent variable being
estimated
• Age
• Gender
• Baseline value for the 8
variables that differed at
p<.10 across the 3
intervention groups and
the Control group at
baseline:
o Medigap insurance (yes/no)
o Private long term care insurance
(yes/no)
o SF-36 Mental Component
Summary score
o Cognitive Performance Scale
score
o Hypertension (yes/no)
o Prior nursing home use (yes/no)
o Number of ADL dependencies
o Number of IADL dependencies
Statistical Analysis
• To compare satisfaction scores at 10 months and
20 months:
– Generalized linear models for repeated measures
• To evaluate the effect of the Nurse intervention
at 22 months on empowerment and health and
disability status:
– Ordered logit
– Linear regression analysis
Beneficiary Baseline Characteristics:
Nurse and Control Groups (N=766)
•
•
•
•
•
Mean age = 77.4 years (range: 23-102)
Age 85+ = 27%
Male = 31%
Minorities = 4%
Mean number of:
– Chronic conditions = 4.4 (SD=2.2)
– ADL dependencies = 2.3 (SD=1.9)
– IADL dependencies = 3.5 (SD=1.8)
Nurse Intervention
• 11 nurses provided services to the 802 patients
in the Nurse and Combination groups
• Average caseload during the Demonstration’s
“steady-state” phase = ~ 65 patients per nurse
• The 382 patients in the Nurse group received a
mean of:
– 19.03 Nurse visits (SD=12.44; range: 0-96) in all
settings (home, hospital, nursing home, MD office)
– 0.98 Nurse visits per month (SD=0.56)
– 3.24 goals developed with the Nurse (SD=3.78)
(range: 0-19) during the time s/he was enrolled
Results: Improvement in Patient Satisfaction
between 10 and 20 Months Postbaseline
Domains
n
10
20
Month
Mean
Month
Mean
t
p
Improved Health
183
3.45
3.61
2.24
.03**
Satisfaction with Nurse Tool
179
3.38
3.60
2.28
.02**
Satisfaction with Nurse
Relationship
183
4.21
4.35
2.73
.01**
Satisfaction with Primary Care
Provider/Health Provider
178
3.35
3.56
2.32
.02**
General Satisfaction with
Nurse Intervention
183
3.72
4.00
3.90
<.01***
Improved Relationship with
Family
167
3.05
3.25
1.56
.12
Satisfaction with Primary Care
Partnership Meeting
136a
3.35
3.73
3.24
<.01***
Results: Improvement in Caregiver Satisfaction
between 10 and 20 Months Postbaseline
n
10
Month
Mean
20
Month
Mean
t
p
Improved Health
125
2.96
2.99
1.19
.24
Satisfaction with Nurse Tool
116
3.11
3.22
1.10
.28
Satisfaction with Nurse Relationship
119
3.64
3.77
1.87
.06*
Satisfaction with Primary Care
Provider/Health Provider
119
3.08
3.07
-0.14
.89
General Satisfaction with Nurse
Intervention
121
3.28
3.40
1.55
.12
Improved Relationship with Family
110
2.65
2.72
0.70
.49
Satisfaction with Primary Care
Partnership Meeting
26a
3.19
3.31
0.62
.54
Satisfaction with Nurse Help to
Reduce Caregiver Stress
116
2.64
2.85
2.17
.03**
Domains
22-Month Adjusted Patient Empowerment
Results for the Nurse Group Variable
Dependent Variable
Nurse Group Variable Results
B
SE B
z/t
p
Health Self-Efficacy
-0.01
0.27
-0.05
.96
Self-Efficacy Scale
-0.25
0.22
-1.13
.26
Internal
Health Locus of
Control Scale
-0.37
0.35
-1.07
.29
Powerful Others
Health Locus of
Control Scale
-0.26
0.39
-0.67
.50
Chance
Health Locus of
Control Scale
-0.33
0.42
-0.78
.43
22-Month Adjusted Health and Functional Status
Results for the Nurse Group Variable
Dependent Variable
Nurse Group Variable Results
B
SE B
z/t
p
Self-Rated Health Status (1-5)
0.06
0.18
0.33
.74
SF-36 Physical Component
Summary (PCS) Score (0-100)
0.14
0.77
0.17
.86
SF-36 Mental Component Summary
(MCS) Score (0-100)
0.81
0.85
0.96
.34
Activities of Daily Living –
Dependence (0-6)
-0.25
0.12
-2.07
.04**
Instrumental Activities
of Daily Living – Dependence (0-6)
-0.16
0.12
-1.33
.18
Discussion: Hypothesis 1
• Our hypothesis was partially supported.
– Patient satisfaction - statistically significant
improvement between 10 and 20 months for 6 of the 7
domains.
– Caregiver satisfaction - significant improvement for 2
of the 8 domains.
• A nurse home visiting review reported better patient
satisfaction for the intervention group in 4 studies (4 other
studies had no significant intervention effect) (Marek &
Baker, 2006).
• A systematic review reported higher patient satisfaction
for the intervention group for 12 of 17 disease
management programs (Ofman, et al., 2004).
Discussion: Hypothesis 2
• Our hypothesis, that the Nurse group patients would
be more empowered and have greater self-efficacy at
the end of the study than would the Control group,
was not verified.
• Several studies have found significantly higher
empowerment scores for empowerment interventions
for orthopedic, diabetes, prostate cancer, and end
stage renal disease patients (Tsay & Hung, 2004).
• A recent review identified 15 articles that have
evaluated the effect on patients of empowermentbased interventions (Aujoulat, d’Hoore, & Deccache,
2007). However, only 2 of these studies had a mean
age of study participants as high as age 65.
Discussion: Hypothesis 2
Possible reasons why our empowerment results differed
from the positive findings often found:
1. Our nurses might not have been sufficiently trained in
patient empowerment, health behavior change, and
chronic disease self-management education.
2. Our patients may have received too little formal
education, had too much disease burden, and/or been
too disabled as a result of advanced age to become
more empowered.
• A review by Auerbach (2001) reports that less
education, more serious or severe illness, and
older age are associated with increased
willingness to relinquish control to others.
Discussion: Hypothesis 2
•
Of 22 studies that examined the relationship
between age and the desire for medical decisionmaking, 17 reported a significant association. Each
of these 17 found that older persons were less
interested in having an active role in medical
decision-making (Say, Murtagh, & Thomsom,
2006).
3. Our measures may not have been appropriate.
4. The patients may have been already
sufficiently empowered so that it would not
have been possible to increase this or selfefficacy above that of the Control group.
Discussion: Hypothesis 3
• Our hypothesis, that health and disability status would be
better at the end of the study for the Nurse patients than
for the Control group, was partially supported.
• Our absence of positive findings for the SF-36 PCS and
MCS scores is similar to the results of 8 nurse home
visiting studies (Marek & Baker, 2006).
• A review of disease management studies for 11 chronic
illnesses reported that the proportion of statistically
significant comparisons in favor of the intervention group
was low (Ofman, et al., 2004):
– 7 of 24 (29%) studies that measured morbidity
– 7 of 35 (20%) that assessed physical functioning
– 5 of 31 (16%) that examined health status/life quality
Limitations
• Generalizability to other geographic areas
• Representativeness of Medicare beneficiaries
with 2+ ADLs or 3+ IADLs that experienced
recent significant health services utilization
• Intervention intensity – It may not have been
intense enough since it relied primarily on
patient self-management and included little
“hands-on” nursing.
Policy Implications
• This study provides evidence supporting the
premise that a multi-component, primary care
affiliated health promotion/disease selfmanagement intervention holds the potential to
delay functional decline among beneficiaries
with ADL dependence.
• Second, this study shows that health promotion
/disease self-management interventions are well
received by beneficiaries.
Conclusion
• This intervention improved patient satisfaction
and resulted in less ADL dependence as
compared with a Control Group at the end of a
22 month treatment period.
• Research is needed to confirm and hopefully
build on our findings.