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Community-Based Care Model for High-Risk Adults with Severe Disabilities

Veronica R. Hill-Milbourne, RN, MS, JD

Sefi R. Knoble, MD

Keith M. Robinson, MD

Kathryn H. Bowles, PhD, RN

Greg Maislin, MS, MA

Objective: Evaluate the effectiveness of a home-based intervention for adults with serious physical disabilities at high risk for poor health outcomes.

Design: A pretest/post-test design; content analysis of case studies.

Setting: Five-county Philadelphia metropolitan area.

Patients and Other Participants: Forty-nine community-dwelling adults aged 20—55.

Intervention: Six-month comprehensive care management intervention implemented by Advanced Practice Nurses (APNs) focused on improvement of functional status or prevention of functional decline; management of health problems; and enhancement of self-direction of care by subjects and caregivers.

Main Outcome Measures: Functional status; total hospitalizations, emergency department (ED) and acute care physician visits; symptom management; depression; quality of life; and satisfaction with care.

Results: Between baseline assessment and nine months post-APN intervention, functional status improved (mean = 33.42 24.97, p = 0.014). There was a trend toward reductions in average hospitalization rate from 1.10 at baseline to 0.68 nine months post-APN intervention and ED rates from 0.90 to 0.50. Acute care visits to physicians increased from 0.52 to 0.95 from baseline to nine months post-APN intervention. The use of home health aides (mean = 2.72 1.37, p = 0.008) and physical therapists (mean = 1.16 0.42, p = 0.001) also decreased from baseline to nine months post-APN intervention. Facilitators and barriers to care are identified.

Conclusions: Findings suggest potential benefit of a comprehensive, individualized intervention coordinated by APNs in improving health and functional outcomes and decreasing the use of

Key Words: care management • functional status • nursing interventions

Home Health Care Management & Practice, Vol. 19, No. 4, 255-266 (2007)
DOI: 10.1177/1084822306298784


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