Improving Quality in Chronic Diseases in the Outpatient Setting Using a CNS-Led Care Management Program.

Area of Science:

• Healthcare Management
• Clinical Nursing
• Public Health

Background:

• Chronic disease management presents significant healthcare challenges, exacerbated by a shortage of primary care physicians.
• Achieving high-quality care standards in chronic conditions is difficult for healthcare professionals.
• Clinical Nurse Specialists (CNSs) are uniquely positioned to address these challenges.

Purpose of the Study:

• To provide evidence supporting the efficacy of CNS-led multidisciplinary teams in outpatient settings.
• To improve quality measures for patients with chronic conditions.
• To evaluate the impact of a care management program on patient health outcomes.

Main Methods:

• A retrospective study analyzed patient data from 2019-2023 within an outpatient internal medicine clinic.
• Pre-post data were collected for weight, BMI, blood pressure, glucose, A1C, and cholesterol levels.
• Four hundred five patient records were compared from initial to most recent care management visits.

Main Results:

• Ten out of eleven t-tests showed statistically significant improvements in health measures.
• Key health indicators such as weight, BMI, blood pressure, glucose, and A1C levels improved.
• High-density lipoprotein (HDL) levels were the only variable that did not show a statistically significant improvement.

Conclusions:

• CNSs, due to their expertise, are ideally suited to lead collaborative, team-based approaches to chronic disease care.
• Multidisciplinary team-led care management programs significantly enhance quality health outcomes in primary care.
• Patient engagement in care management programs demonstrates substantial health improvements, reducing the risk of complications.