Related Experiment Video
Updated: Oct 8, 2025
A Novel Digital Platform for a Monitored Home-based Cardiac Rehabilitation Program
Published on: April 19, 2019
Care coordination for rural residents with chronic disease: Predictors of improved outcomes
Andrew R Hansen1, Susan F McLendon2, Haresh Rochani3
1Department of Health Policy and Community Health, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia.
Objective:
The purpose of this study was to assess the effect of an integrated system of coordinated care on chronic disease health outcomes of patients with poorly controlled diabetes, hypertension, and congestive heart failure (CHF) living in a rural area.
Design And Sample:
Longitudinal study of patients aged 18 years or older, living in a rural area, with diabetes glycated hemoglobin (A1C) > 8%, hypertension blood pressure (BP) > 150/90, heart failure, and suffering excessive weight gain and hospital admission in last 6 months.
Measures:
Dependent variables were A1C, cholesterol, microalbumin, body mass index (BMI), BP, emergency department (ED) visits, and hospital admissions. Predictor variables included time in the program, age, sex, race, and Diabetes Self-Management Education (DSME) completion. Descriptive variables included telemedicine and specialty referrals and travel savings.
Results:
Time had a significant effect on A1C, microalbumin, BP, and ED visits. Race, sex, and DSME also impacted A1C and BP outcomes.
Conclusions:
Length of time in the program played a crucial role in improved outcomes for patients in the program for a year or more. Long-term, consistent reinforcement in the form of education and coordinated care provided by certified care coordination nurses achieve better health outcomes.
More Related Videos
Related Concept Videos
01:15Methods of Documentation VI: Case Management Model
For example, a patient with a chronic...
01:29Documentation in Long-Term and Home Healthcare Setting
Long-Term Care Facilities
01:28Chronic Kidney Disease III: Interprofessional Care
01:18Chronic Kidney Disease IV: Nursing Management
01:30Chronic Obstructive Pulmonary Disease-V: Nursing Management
Assessment
01:26Methods Of Healthcare Delivery System
Managed Care System:
The managed care system is designed to control the cost while maintaining the quality of care. The patient's care from admission to discharge is planned by the primary care provider or the case manager, also known as the gatekeeper. In a managed care system, the number of care providers is...