As U.S. healthcare trends toward team-based care with greater focus on preventive services, nurses are stepping into leadership roles and producing positive clinical outcomes. However, this shift in cardiovascular care may require an overhaul of cultures and systems by providers—as well as a fresh look at reimbursement.
Case management & preventive care
In its 2009 report, the World Health Organization estimated that deaths from cardiovascular disease (CVD) will rise to 23.4 million, an approximate 37 percent increase from 2004 rates, posing an ever-increasing burden of morbidity and mortality in both high- and low-income countries. To combat the problem in the U.S., medical home initiatives and reimbursement changes are driving CV care toward prevention as opposed to treatment. This type of case management will require healthcare professionals to consider psychological and behavioral aspects of care in addition to the knowledge of medicine.
“There is an enormous need for advanced coordinated care. Our current healthcare system with a single provider meeting with a single patient to take care of a single problem is just not efficient or effective,” says Kathy Berra, MSN, RN, ANP, clinical director at Stanford Heart Network in Stanford, Calif. She adds that nurses are trained for a coordinated-care approach. “If you’re a nurse practitioner in the U.S., you can diagnose and treat, and all nurses are taught to take a very holistic approach to care that incorporates the patient and family.”
If a patient needs to stop smoking but his or her significant other smokes, “then you have to deal with both of them or it’s less likely to be successful with that patient,” Berra explains.
And the evidence isn’t just anecdotal. In a large observational study of 193 Danish general practices assessing 12,960 patients with type 2 diabetes (age range 40 to 80 years), practices with well-implemented nurse-led type 2 diabetes consultations were compared with practices with no nurses for the hemoglobin A1c (HbA1c) scores of their patients as an indicator of outcomes (Primary Care Diabetes 2012;6:221-228). Only 17.2 percent of patients in the nurse-led case management arm failed to reach their HbAlc goal vs. 68 percent in the primary care arm.
Positive outcomes with nurse-led case management are not new. About 15 years ago, the Cardiac Hospitalization Atherosclerosis Management Program (CHAMP) at the University of California, Los Angeles, focused on the initiation of guideline-based therapies for CVD risk reduction in hospitalized patients with coronary artery disease (Am J Cardiol 2001;87:819-822). CHAMP demonstrated a significant reduction in morbidity and mortality in patients receiving nurse-directed case management compared with usual care one year after hospital discharge. This study became the cornerstone for the American Heart Association’s Get With the Guidelines initiative (Am Heart J 2010;159:207-214).
Despite this evidence, healthcare traditionally has been slow to change care delivery. Yet, the current confluence of events, along with the push to reduce healthcare costs, has escalated efforts to tackle new approaches. “Administrators are looking for cost-effective models of care, causing case management and transitional care models to gain prominence,” says Sandra B. Dunbar, DSN, RN, associate dean for academic advancement at Emory University’s School of Nursing in Atlanta. “They are recognizing the need for system changes, as well as role changes.”
Case management is particularly effective in preventive care, as it calls for a more holistic approach to a patient. “We currently have a crisis in secondary prevention, including obesity, lack of physical activity, smoking, high cholesterol, hypertension, diabetes and the aging of the population obviously complicates things as well,” Berra says. “Now, we’re going to need teams led by medical professionals, whether they are primary care physicians (PCPs), internists, nurse practitioners and nurses, who are then supported and work closely with nurses and other healthcare professionals, such as exercise physiologists, psychologists, nutritionists and physical and occupational therapists.”
She points to cardiac rehab as the best model because after a patient is hospitalized due to a heart condition, he or she is referred to a cardiac rehabilitation program for multifactorial management to reduce CVD risk. “This strategy has resulted in a 25 percent reduction in mortality,” Berra