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

Abstract

Background and objectives: The magnitude of chronic disease management is a daunting health care problem at the same time when there is a reduction in primary care physicians, making achieving high-quality standards and goals extremely challenging for health care professionals. The research objective for this project was to provide evidence to support the use of clinical nurse specialist (CNS)-led multidisciplinary teams in the outpatient setting to improve quality measures in chronic conditions.

Methods: Patient data were collected from 2019 to 2023 for patients engaging in a multidisciplinary care management program in an outpatient internal medicine office. Pre-post data were collected for weight, body mass index, blood pressure, glucose levels, A1C levels, cholesterol levels, and medical diagnosis. Data were recorded for the first care management patient visit and compared to the most recent care management visit. Four hundred five patient records were included in the study.

Results: Ten of the 11 t-tests evaluated were statistically significant in improving health measures. The only variable that did not emerge significant was HDL.

Conclusions: Because of their education and training, CNSs are the best-suited health professionals to lead a team-based collaborative approach to chronic disease care management and improve quality health outcomes in primary care environments. Patients choosing to participate in care management programs demonstrated significant improvement in their health, therefore reducing risk for health, complications.