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conducting groups is essential when the program is offered in a Important Lessons for Program
72
group format. Most often, nurses have bachelor degrees or mas- DISPLAY 42-1 Implementation in Disease Management
ter degrees and have been specially trained for the position. Many
are Advanced Practice Nurses specializing in case management or •Physician leadership/support is key to program viability
disease management. A strong background in cardiovascular nurs- • Ongoing marketing is essential
ing (minimum 3 years) and cardiac rehabilitation are desirable • Program modifications save time and resources
qualifications for disease management. • Protocols require annual updates and alignment with
Core competencies in chronic disease management may be national guidelines
mastered through a curriculum that includes knowledge of the •Defining caseload requirements and reevaluating is nec-
essary for quality control
disease process, medical management of risk factors, treatment
protocols, lifestyle and psychosocial interventions, information
systems, and institutional operations. Patient education and be-
havioral counseling skills include motivational interviewing and
adherence counseling. An ability to operationalize treatment pro- talization rates and costs for heart failure. These are highlighted
tocols surrounding the initiation and titration of medications, in Display 42-2.
symptom management, documentation in medical records, and Many challenges continue to confront those involved in dis-
coordination of care are core competencies that must be mastered. ease management, offering future opportunities for research and
Like those involved in public health and community nursing, dis- for those conducting clinical programs. Disease management pro-
ease management nurses must be committed to following patients grams have typically focused on what is often called a “single dis-
and families on a long-term basis. ease state” or “carve out.” These specialty programs for high-cost
Much of the training for disease management occurs on the patient populations treat only a single chronic condition such as
job, although more schools of nursing are offering classes that sup- diabetes or heart failure. However, many individuals have predis-
port skills for disease management. Best practice programs 109 of- posing risk factors and comorbid conditions that determine their
fer in-depth training to nurses managing multiple risk factors oc- functional status and prognosis. For example, more than half of all
curring over 2 weeks. Didactic lecture, role playing, and case study rehospitalizations for heart failure are caused by coexisting condi-
presentation are followed by 1 week of preceptorship training tions that impact the disease, such as hypertension and coronary
with other experienced disease management nurses in the field. artery disease, or unrelated conditions, such as chronic obstructive
Nursing organizations, such as the Preventive Cardiovascular pulmonary disease. 92 Moreover, the overlap of cardiovascular risk
Nurses Association (PCNA), 123 are committed to educating factors (dyslipidemia, obesity, hypertension, and smoking) is sig-
nurses to take on expanded roles in preventive cardiovascular nificant. Thus, the need for managing multiple risk factors con-
nursing. They offer regional and national training, web-based currently is noteworthy and requires continued research. As ad-
continuing education online (CEU) courses and important pub- herence to guidelines by physicians and systems becomes more
lications including cardiovascular guidelines and tools that sup- common place, allowing achievement of better patient outcomes,
port those undertaking disease management roles. a more central role for nurses in disease management is likely to
reside with an elderly and aging population that is burdened by
multiple diseases and associated conditions. Naylor et al. have
started to addressed many of the factors associated with the older
THE UNRESOLVED ISSUES FOR adults, 49,91,108 early findings suggest promise for the future.
DISEASE MANAGEMENT A second challenge relates to intervention components and the
duration of follow-up. Although disease management models
Although disease management has not yet reached widespread focus on multiple interventions, there is large variation in the
application in clinical practice, it holds promise as a new way of
delivering care to those at high risk for and those with established
cardiovascular disease. The success of using nurses to coordinate
disease management programs has most often resulted in more DISPLAY 42-2 Key Features of Successful Programs
frequent medication changes, an increase in the use of combina- of Care in CHF
tion drug regimens, less expensive medications, and an increase
in short-term adherence. These results are in large part because of • A commitment to individualized health care
the use of defined protocols and increased patient contact time • A multidisciplinary approach to managing the patient
• A major role for a specialist nurse to assess patient
for education and behavioral counseling. In addition, a greater needs and provide for ongoing management within a
achievement of goals such as a reduction in blood pressure, cho- supportive multidisciplinary environment
lesterol, and glucose control has been realized. A by-product of • At least one home visit for a comprehensive assessment
comprehensive care in patients has produced a reduction in uti- of the patients circumstances
lization for all causes (emergency department visits and hospital- • The promotion of self-care behaviors
izations), something not expected by many in the field. 124 As • Increased levels of monitoring in “high-risk” patients
noted in Display 42-1, organizations implementing disease man- • The application of optimal, evidence-based pharmaco-
agement programs for more than 10 years suggest several impor- logical treatment with flexible protocols for changes in
tant lessons for those developing new programs. In addition, patient status and titration to maximal tolerated doses.
Stewart and Horowitz 69 have highlighted a number of factors
Adapted with permission from Stewart, S., & Horowitz, J. (2003). Specialist nurse
that appear to be important in the overall development of those
management programmes: Economic benefits in the management of heart failure.
disease management programs that successfully reduced rehospi- Pharmacoeconomics, 21(4), 225–240.