In the latter part of the 20th century, healthcare reform sparked a transition in the nursing curriculum from acute care to primary and secondary care. Faculty responded to this challenge by redesigning curricula in creative ways. The transitional curriculum introduced community clinical experiences designed to challenge students to practice in diverse, nontraditional sites and in more independent ways. Such practice requires the nurse to function as designer, coordinator, and manager of patient care in addition to the traditional provider role. Additionally, the transitional curricula emphasized the roles of communicator, educator, facilitator, listener, and advocate to a greater degree. For students to achieve competence in the above roles, the curriculum must include learning activities that allow them to practice as case managers in the community. This paper presents the "Seven A's" as a framework for students to gain an understanding of and engage in the role and process of case management in the community.
[Show abstract][Hide abstract] ABSTRACT: Taiwanese health authorities are increasingly applying case management as a health care delivery strategy in the community. However, most Taiwanese public health nurses (PHNs) do not receive case management education because there are few education programs available. Several limitations in existing evaluative studies of case management continuing education programs were identified. These methodological weaknesses limit the conclusions that can be drawn about the effectiveness of these education programs. Hence, the purpose of this study was to develop, implement and evaluate a collaborative case management continuing education program for Taiwanese PHNs. The study was divided into three phases, with an expanded theoretical framework used to guide the program development, implementation and evaluation. Phase One conducted focus group discussions in order to assess the educational needs of Taiwanese PHNs. Phase Two developed a collaborative education program based on the findings of a literature review and the needs assessment. The initial program was evaluated by an expert panel and pilot testing was undertaken. Phase Three implemented and evaluated the program using an experimental research design and mixed evaluation methods. Three outcome levels were assessed, namely reaction, learning and performance by examining changes in PHNs' case management knowledge, skills and practice. The participants in the study were PHNs employed in health centres in Taipei City. The program itself involved 16 hours of workshops through four half-day sessions, conducted every two weeks during the participants' work time and at their workplace. Two types of data, focus group data and questionnaire data, were collected during the course of the study. The focus groups were conducted before and after the program delivery, for the needs assessment and program evaluation, using a subset of the participants. The focus groups were moderated by the researcher, who used a focus group discussion guide to collect data. The other data set was collected using self-report questionnaires. The participants were randomly allocated into two groups using cluster sampling, the experimental and comparison groups. Both groups were given questionnaires before the education program commenced, and then again eight weeks after the program was completed. For ethical considerations, PHNs in the comparison group also received the same program after data collection. The results revealed that the majority of participants were satisfied with the program. The education intervention significantly improved PHNs' case management knowledge, performance skills confidence, preparedness for case manager role activities, frequency of using case management skills, and frequency of using these role activities. A number of changes in case management practice were reported, in particular that the participants tended to follow the case management process more often and focus more on the quality of case management. This study was guided by an integrated theoretical framework, and used a clustered randomised controlled design to assess the effectiveness of the program across multiple levels of outcomes, hence addressing the design deficits identified in the prior evaluative studies. This study therefore provides an important contribution to the fields of nursing and case management by developing, implementing and evaluating a case management education program. Additionally, the program itself offers an evidence-based educational experience for PHNs and provides a new tool for nursing education in the context of Taiwan.
[Show abstract][Hide abstract] ABSTRACT: Case-management (CM) can positively influence chronic disease care by facilitating guideline-concordant interventions that improve outcomes through intensive, individualized, longitudinal care. Implementation of CM, however, is difficult. We have identified lessons learned from a cardiovascular risk reduction CM program that may aid future CM implementation.
Heart to Heart is both a clinical trial and program dissemination project implementing CM for persons at elevated risk of coronary heart disease (CHD) events in a multiethnic, low-income population in a county health system. Patients were randomized to CM plus usual primary care (N = 212) or primary care alone (N = 207). CM patients received face-to-face nurse and dietitian visits (mean of 14 hours) over 17 months. Visits emphasized behavior change, risk-factor monitoring, and guideline-based pharmacotherapy. A total of 341 patients (81%) were available for follow-up. This CM model is currently transitioning to a County-run program.
Findings demonstrated statistically significant reductions in mean Framingham Risk for CM versus usual primary care (1.56% absolute decrease in 10-year CHD risk, P = 0.007). Favorable changes were noted across most major CHD risk factors. Lessons learned are the need for the following: (1) Strategies for implementing CM in low-income, ethnically-diverse populations, (2) Methods for developing clinically more effective CM, and (3) Approaches to increase the efficiency of cardiovascular CM.
CM for cardiac risk factors faces notable implementation barriers, particularly in County health systems. Specific implementation solutions recommended may help confront these barriers and improve diffusion of this evidence-based and patient centered model of care.
Critical pathways in cardiology 01/2008; 6(4):173-9. DOI:10.1097/HPC.0b013e31815b5609
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