A case study exploring therapeutic communication as a mechanism for delivery of integrated care management (icm) by home healthcare (hhc) nurses

Background: There is ample evidence that nurse-led micro level integrated care management (MICM) is needed to fully address the health needs of homebound elderly HHC patients. MICM capitalizes on the therapeutic potential inherent in nurse-patient relationships to promote improved care coordination and health outcomes. However, effective MICM strategies are not part of existing HHC clinical practice. Instead, existing community programs deliver meso- level ICM, targeted at structural system changes. Integrative processes need to be delivered directly by nurses to patients with health complexity, to optimize health outcomes. This case study is a first step in assessing the potential for leveraging nurse-patient relationships as the vehicle for generalist HHC nurses to deliver MICM. Purpose: Our project had four phases: (Phase 1) analysis of nurse perceptions, interactions, and experiences with depression and disability care management (DCM); (Phase 2) exploration of nurses’ use of care management and therapeutic strategies during home visits; (Phase 3) Assessed the extent to which HHC nurses improved DCM subsequent to change in screening; (Phase 4) Development and evaluation of an online education/training course. Wagner’s CCM and Peplau’s interpersonal relationship theory guided study design and analyses. Methods/Design: Phases 1 & 2: Purposeful criterion-based sampling was used to obtain a sample of 16 registered nurses who were full-time employees providing agency-based HHC services for five 60+-year-old persons (3 women; 2 men) with 4+ chronic illnesses, and moderate levels of disability/ depression. Conventional content analysis methods were used to code and categorize data: 12 in-depth nurse interviews; 2 focus groups; 20 observation visits. Phase 3: Retrospective chart review and analyses of one hundred 60+-year-old persons with chronic illnesses, disability and depression to assess the extent to which HHC nurses improved DCM, subsequent to change in depression screening requirements. Phase 4: To expand nurses MICM and communication skills, we developed, and pilot-tested, a nurse education online program with eight nurses. Findings: Phases1 & 2: Nurses demonstrated confidence in caring for older patients with disabilities but were less likely to integrate depression and disability care in daily practice. Drawing upon their clinical knowledge and interpersonal skills, nurses built relationships and fostered trust. But, despite abilities to make connections, multiple missed opportunities prevented nurses from engaging in productive interactions, challenging the sustainability of therapeutic relationships (i.e., disconnections). Leading to feelings of mutual frustration, emotional uneasiness, and dissatisfaction for both nurses and patients. Phase 3: Chart review outcomes revealed lack of depression training were threats to increasing nurse proficiency in promoting DCM with patients; leading to worsening patient depression/disability. Phase 4: Course showed that all nurses improved on modules (ICM, DCM, Goals, Communication). Conclusion: Effective nurse therapeutic communication is essential to achieving productive interactions with older patients, improving both the quality of these relationships and delivery of MICM. Yet, studies testing the efficacy, implementation, and effectiveness of MICM in HHC are minimal. Thus, nurse-led interventions are needed which provide an opportunity to advance the science, and test delivery of physical/mental health at the micro level, with integration of system level resources, to optimize patient outcomes.