Nurse case management to improve risk reduction outcomes in a stroke prevention clinic.
ABSTRACT Stroke prevention clinic health care professionals are mandated to provide early access to neurological consultation and treatment, diagnostic testing, and behavioural risk factor management for clients with transient ischemic attack or mild non-disabling stroke. Clinic nurses collaborate with clients and interprofessional teams to support risk factor reduction to prevent recurrent stroke events. Although hypertension is the most important modifiable risk factor for stroke, broader evidence indicates that adherence to prescribed medications may be less than 50%. One clinic identified a need to improve risk factor outcomes through identifying clients with uncontrolled hypertension, cognitive, self-eficacy and/or adherence characteristics predictive of non-achievement of blood pressure targets. To address this need, an expanded nurse case management care delivery model was pilot tested for feasibility in a participant sample of 20 clients. Motivational interviewing and self-management approaches were combined with interventions designed to improve adherence:facilitation of the simplification of medication routines, providing memory cues and home self-monitoring equipment, counselling, and six-month nursing follow-up. Results demonstrated that an expanded nurse case management model of care delivery is feasible with only a modest impact on clinic resources. At six months, there were significant reductions in blood pressure and increases in medication self-efficacy and adherence for selected clients identified with high risk for stroke and non-achievement of treatment outcomes.
Full-textDOI: · Available from: Linda Gould, Apr 30, 2014
SourceAvailable from: Huana Carolina Cândido Morais[Show abstract] [Hide abstract]
ABSTRACT: OBJECTIVE To analyze strategies for self-management support by patients with stroke in the light of the methodology of the five A's (ask, advice, assess, assist and arrange). METHODS Integrative review conducted at the following databases CINAHL, SCOPUS, PubMed, Cochrane and LILACS. RESULTS A total of 43 studies published between 2000 and 2013 comprised the study sample. All proposed actions in the five A's methodology and others were included. We highlight the Assist and Arrange, in which we added actions, especially with regard to the use of technological resources and joint monitoring between patients, families and professionals. No study included all five A's, which suggests that the actions of supported self-management are developed in a fragmented way. CONCLUSION The use of five A's strategy provides guidelines for better management of patients with stroke with lower cost and higher effectiveness.Revista da Escola de Enfermagem da U S P 01/2015; 49(1):136-43. DOI:10.1590/S0080-623420150000100018 · 0.50 Impact Factor
[Show abstract] [Hide abstract]
ABSTRACT: The purpose of this study was to determine whether interventions including components to improve adherence to antihypertensive medications in patients after stroke/transient ischemic attack (TIA) improve adherence and blood pressure control. We searched MEDLINE, EMBASE, CINAHL, BNI, PsycINFO, and article reference lists to October 2012. Search terms included stroke/TIA, adherence/prevention, hypertension, and randomized controlled trial (RCT). Inclusion criteria were participants with stroke/TIA; interventions including a component to improve adherence to antihypertensive medications; and outcomes including blood pressure, antihypertensive adherence, or both. Two reviewers independently assessed studies to determine eligibility, validity, and quality. Seven RCTs were eligible (n=1591). Methodological quality varied. All trials tested multifactorial interventions. None targeted medication adherence alone. Six trials measured blood pressure and 3 adherence. Meta-analysis of 6 trials showed that multifactorial programs were associated with improved blood pressure control. The difference between intervention versus control in mean improvement in systolic blood pressure was -5.3 mm Hg (95% CI, -10.2 to -0.4 mm Hg, P=0.035; I(2)=67% [21% to 86%]) and in diastolic blood pressure was -2.5 mm Hg (-5.0 to -0.1 mm Hg, P=0.046; I(2)=47% [0% to 79%]). There was no effect on medication adherence where measured. Multifactorial interventions including a component to improve medication adherence can lower blood pressure after stroke/TIA. However, it is not possible to say whether or not this is achieved through better medication adherence. Trials are needed of well-characterized interventions to improve medication adherence and clinical outcomes with measurement along the hypothesized causal pathway.Journal of the American Heart Association 07/2013; 2(4):e000251. DOI:10.1161/JAHA.113.000251 · 2.88 Impact Factor
[Show abstract] [Hide abstract]
ABSTRACT: Clinical Pharmacy Specialists (CPSs) and Registered Nurses (RNs) are integrally involved in the Patient Aligned Care Teams (PACT) model, especially as physician extenders in the management of chronic disease states. CPSs may be an alternative to physicians as a supporting prescriber for RN case management (RNCM) of poorly controlled hypertension. To compare CPS-directed versus physician-directed RNCM for patients with poorly controlled hypertension. Non-randomized, retrospective comparison of a natural experiment. A large Midwestern Veterans Affairs (VA) medical center. Utilizing CPSs as alternatives to physicians for directing RNCM of poorly controlled hypertension. All 126 patients attended RNCM appointments for poorly controlled hypertension between 20 September 2011 and 31 October 2011 with either CPS or physician involvement in the clinical decision making. Patients were excluded if both a CPS and a physician were involved in the index visit, or they were enrolled in Home Based Primary Care, or if they displayed non-adherence to the plan. All data were obtained from review of electronic medical records. Outcomes included whether a patient received medication intensification at the index visit, and as the main measure, blood pressures between the index and next consecutive visit. All patients had medication intensification. Patients receiving CPS-directed RNCM had greater decreases in systolic blood pressure compared to those receiving physician-directed RNCM (14 ± 13 mmHg versus 10 ± 11 mmHg; p = 0.04). After adjusting for the time between visits, initial systolic blood pressure, and prior stroke, provider type was no longer significant (p = 0.24). Change in diastolic blood pressure and attainment of blood pressure < 140/90 mm Hg were similar between groups (p = 0.93, p = 0.91, respectively). CPS-directed and physician-directed RNCM for hypertension demonstrated similar blood pressure reduction. These results support the utilization of CPSs as prescribers to support RNCM for chronic diseases.Journal of General Internal Medicine 04/2014; 29. DOI:10.1007/s11606-014-2774-4 · 3.42 Impact Factor