Use of Community Services,Satisfaction of Family

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Purpose of the Pilot ProgramThe pilot program aimed to determine the impactof a care coordination and support strategic part-nership (CCSP) between a nursing telephone pro-gram and a home care agency on clinical efficacy

Use of Community Services, Satisfaction of Family Caregivers, Healthcare Use, and Cost

Joseph B. Engelhardt, PhD, Theresa Kisiel, NP, Jeremy Nicholson, MSW, Lori Mulichak, RN, James DeMatteis, MD, and Daniel R. Tobin, MD

A strategic partnership between a nursing care coordination telephone support program and a home health-care agency was evaluated. The study was supported by the Centers for Medicare and Medicaid. According tothe results, the partnership was a clinically effective service that proved satisfactory to family caregivers, im-proved the use of community services, and reduced inpatient use and costs without affecting mortality.

in the management of common problems withchronic illness (in this evaluation, Alzheimer’sdisease), use of community services, caregiversatisfaction with CCSP services, inpatient health-care use, and cost.

vol. 26 • no. 3 • March 2008 Home Healthcare Nurse 167

Support for the effort described in this reportwas provided through a demonstration fundedby the Centers for Medicare and Medicaid (Tobin& DeMatteis, 2007). The sample consisted of pa-tients with Alzheimer’s disease (AD) and theircaregivers.

Care coordination efforts in the telephonecomponent of CCSP included traditional activities(e.g., linking services, health education). How-ever, the relative weight of coordination activitiesin this model emphasized managing emotional re-actions and providing practical guidance to pro-mote optimal coping and self-management. Thisfocus promotes adaptation and helps people feelmore comfortable taking responsibility for man-aging illness. The telephone component of CCSPaddresses ongoing concerns about coping withillness and maintaining an intact sense of self.

The telephone health counseling componentwas developed from a synthesis of widely used,empirically based approaches for supporting themanagement of serious illness, including cogni-tive-behavioral, task-centered, health behaviorchange, problem-solving, and best practices incare coordination models, as well as EOL careand psychosocial nursing (American Academy ofFamily Physicians, 2007; Barry, 1996; Chang et al.,2004; Chen et al., 2000; Reid & Epstein, 1977; Roll-nick et al., 2005; Tobin, 2000; Wright et al., 2006).

The CCSP is manualized as an 80-hour trainingprogram and supplemented with continuing edu-cation modules that detail 8 algorithms of caredesigned to meet the many biopsychosocialneeds of families coping with serious chronic ill-ness (Engelhardt et al., 2006). For example, 1 ofthe 8 algorithms is emotional support, which isdesigned to help patients and families cope withthe emotional sequelae of chronic illness. It is de-livered in 2 modes: specific and nonspecific. Non-specific emotional support is the provision of em-pathy, genuineness, and warmth in all contacts.Specific provision of emotional support is usedwhen there is an emotion that requires accurateidentification, acknowledgment, and problem-solving effort. For instance, a caregiver con-strued a welter of distressful emotions she expe-rienced as a sign she was becoming emotionallyunstable. Upon examination, the caregiverlearned from CCSP that she was experiencingcaregiver role strain. This reframe from a patho-logic disorder into a situational reaction resultedin a plan whereby she divided caregiving duties

Literature ReviewSupport for family caregivers is an importantgoal of home health nursing programs (Bradley,2003). The duties involved in the care ofAlzheimer’s patients exhaust many caregivers,putting their own health at risk and making themmore likely to institutionalize care receivers. Inthe United States, 5.1 million older persons havedementia, a number expected to rise dramati-cally (Alzheimer’s Association, 2007). Conse-quently, there is a need to examine innovationsthat help caregivers maintain their capacity tocontinue providing care.

A CCSP comprised the basis for the organiza-tional partnership between a community-basedcertified home healthcare agency (HHA) and ageographically remote, organizationally inde-pendent nursing telephonic health counselingsupport center. Using a modified Outcome andAssessment Information Set (OASIS, 2007), HHAregistered nurses (RNs) provided the home as-sessment visits.

The OASIS questions focused on home safetyconcerns (e.g., living arrangements, environmen-tal impediments, safety and sanitation hazards,supportive assistance, and indications of a vul-nerable situation). Other questions helped to con-firm caregiver telephone reports about patientfunctioning (e.g., cardiovascular, respiratory, neu-rologic, psychosocial, and medication data).

The HHA RN received referrals from the tele-phone-based RN, who had already interviewedcaregivers after their consent to participate inthis pilot program had been obtained. Both clini-cians conferred after assessment visits. Subse-quent care plan development incorporated HHARN input, which was based on nursing assess-ment skill and home assessment findings. In thissample, HHA services were limited to assessmentvisits, and skilled care visits were not provided aspart of this intervention.

A strengths-based telephone health counsel-ing program delivered by RNs was developed toaddress well-known shortcomings in health deliv-ery. These include deficiencies in health literacyand limitations in the safety and quality of care,care coordination, caregiver support, financingof care, patient-physician communication, adher-ence to treatment plans, and use of communityresources, as well as neglect of affective compo-nents of illness and avoidance of discussing end-of-life (EOL) care (Institute of Medicine, 2003).

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among her siblings, with the result that the straindissipated.

This CCSP in this study is an organizationalcollaboration of health providers. Its features in-clude the following: (1) the CCSP is not depend-ent on existing payers or payment structures; (2)the CCSP can operate with private-duty organiza-tional components of HHA in which patients in-fluence access to services by ability to pay forcare; (3) the administrative governance of part-ner organizational structures are independent;(4) the partners are not limited to operating in acommon geographic area; and (5) although theCCSP was limited to 1 disease in this evaluation,it can support a range of serious chronic illnessstates.

MethodsThe study design included descriptive, before-after, and historical control components. A pur-posive sample of 36 patients and their caregiversparticipated. To evaluate outcomes for health-care use and cost, 113 historical controls (HC)who constituted the pilot-site population with ADwas used. Of the 36 caregiver-patient dyads en-rolled, 32 actively participated. The evaluationwas conducted from July 31, 2005 to March 31,2007, whereas HC use and cost was from 2005.The criteria for inclusion in the evaluation wereMedicare eligibility, diagnosis of AD, age of 55years or older, dementia judged as moderate by aphysician investigator (J.D.), functional inde-pendence judged as moderate, and English-speaking caregiver. The HCs were identified byusing AD-related dementia International Classifi-cation of Diseases (ICD)-9 codes.

The participants received the CCSP model ofcare coordination. The program activities fo-cused on caregivers, and the outcomes capturedthe impact of the program on caregivers and pa-tients. Descriptive methods were applied to eval-uate caregiver satisfaction (using the Client Expe-riences Questionnaire; Corcoran & Fischer, 2000,pp. 163-164) and use of community supports(using open-ended interviews). Community serv-ices also were evaluated through open-ended in-terviews with participating clinicians. A nursingoutcomes measurement tool, the Nursing Out-come Classification (NOC) system, was used tomeasure clinical efficacy (Moorhead et al., 2004).Within-group t tests also were used to evaluateclinical efficacy. Between-group t tests and chi-

square tests were used to compare CCSP and HCin terms of health use and costs and percentageof deaths, respectively. Intent-to-treat analysiswas used for health use and cost analysis. Thispilot program was conducted in 1 medical centerand an affiliated HHA.

Characteristics of ParticipantsThe mean age of the patients was 78.8 years(Table 1). Of the 36 consenting CCSP partici-pants, 22 were men (61%). The CCSP and HC wereevaluated for differences in age and sex thatmight contribute to differences in health use andcost. No significant differences were found forage (t = 0.147) or sex (χ2 = 2.205).

The 32 caregiver participants included 23spouses (72%) and 9 adult children (28%), 11 ofwhom were men (34%). Of the patient-caregiverdyads, 22 (88%) identified at least 1 caregiver-centered issue (e.g., caregiver strain). There were16 dyads (64%) that identified at least 1 patient-centered issue (e.g., medical problems) and 13dyads (52%) that identified both types of issues(e.g., family relocation concerns).

Results Clinical EfficacyClinical efficacy was evaluated by comparing be-fore-after ratings for participating patients andcaregivers on identified problem outcomes de-rived from NOC. For example, knowledge deficitis rated using 5 levels: none, limited, moderate,substantial, and extensive. The study found NOCratings available for 22 dyads. In 14 cases, beforeand after ratings were not available. In 3 cases,families were enrolled but did not participate. In1 case the data were missing, and in 7 cases nospecific problems were identified between thenurse and the caregiver. The participants inthese 7 cases reported that the caregiving situa-tion was quiescent in the initial call.

Where problems were identified, improvedoutcomes were observed in all the cases. Table 2shows that the average NOC baseline score (pre-rating) was 2.14 and the average outcome (post-rating) was 4.18 out of a possible 5. This increasewas statistically significant (p < .001), and the in-crease suggests clinically significant improve-ment as well. For example, applying the baselinerating of 2.14 from Table 2 to knowledge deficitfor AD, the NOC descriptor for this level is “lim-ited” knowledge. That is, on the average, care-


givers possessed “limited” knowledge at base-line. Clearly, limited knowledge by caregivers isundesirable for optimal management of patientswith dementia. The descriptor for the 4.18 ratingis “substantial” knowledge. Thus, family care-givers’ knowledge about dementia improvedfrom “limited” to “substantial.” Clinically, the dif-ference in levels of knowledge is meaningful.

Table 2 also shows another clinical aspect ofCCSP: percentage of deaths. There were 4 deaths inCCSP (11%) and 5 deaths in HC (4%). The differ-ence was not significant according to a chi-squaretest, suggesting that CCSP has no impact on thedeath rate.

Family Caregiver SatisfactionSatisfaction with CCSP by participating care-givers was evaluated using the Client Experi-ences Questionnaire (CEQ). Of the 22

caregiver/patient dyads that completed workingon problems, 11 (50%) provided satisfaction in-formation. The CEQ score descriptions are 1 (ex-tremely satisfied), 2 (somewhat satisfied), 3 (nei-ther satisfied nor dissatisfied), 4 (somewhatdissatisfied), and 5 (extremely dissatisfied). Onthe average, the satisfaction score was 1.89 ±.524. The average rating was between somewhatand extremely satisfied.

Improved Use of Community ServicesImproved use of community services was cap-tured using open-ended interviews withproviders and caregivers. There were referrals toa wide range of community supports. Of the 32CCSP dyads that participated in calls or agreed toreceive health education information, 29 (91%)were referred to support groups, 21 (66%) werereferred to nonmedical support services (e.g.,

Table 1. Age and Sex of Patients by Group

Table 2. CCSP Clinical Efficacy

Group

Variable CCSP HC df t χ2

(n = 36) (n = 113)

M SD M SD

Age 78.78 5.82 78.49 11.37 147 0.147

n p n p

Male 22 61% 53 47%Sex 1 2.205

Female 14 39% 60 53%

Variable Group n df t χ2

n P

CCSP 4 11% 36Deaths 1 2.151

HC 5 4% 113

M SD

Baseline 2.14 0.710 2221 11.369*

Post-test 4.18 0.588 22

*p < .001

NOCRating


local area Agency on Aging), 15 (47%) were re-ferred to medical services (e.g., VA Medical Cen-ters), and 14 (44%) were referred to hospice forinformation or services.

The most striking improvement in the use ofcommunity resources was the frequency withwhich CCSP connected participants with theAlzheimer’s Association. No participants usedthese services at the time of enrollment, yet all 32caregiver/patient dyads were given informationabout how use of the Alzheimer’s Associationservices might improve their particular situations.

Healthcare Use and CostsTable 3 shows healthcare use and cost for CCSPand HC. As shown, CCSP patients had fewer inpa-tient admissions (11% vs 74%; p < .000) andshorter average lengths of stay (LOS) (1.00 vs5.29; p < .000). Data from all 36 consenting partic-ipants were included to provide an intent-to-treatanalysis for pilot-site health use and cost out-comes. To compensate for differences in time atrisk for healthcare use, the results were proratedto reflect annual use rates where CCSP demon-strated shorter LOS (1.26 vs 5.29; p < .000). Also,CCSP showed lower average inpatient costs($10,372.53 vs $30,650.28; p <.011). These costsalso were prorated, with CCSP participants show-ing lower average inpatient costs ($12,988.53 vs$30,650.28; p < .011) (Table 3).

Adjusting for CCSP CostsTo evaluate any cost effects that delivery of CCSPmay have had on the differences shown in Table3, pilot-site costs in effect during the pilot pro-gram were applied to the analysis. Program costswere calculated by multiplying average call-cen-ter time (142.5 minutes per case, or 2.38 hours) by36 patients, which yielded 86 hours of CCSP caredelivery. One additional hour was added for eachcase to estimate time expenditure for indirect ad-vocacy services and documentation, giving a totalclinician time of 122 hours. The average hourlywage of a clinician plus an administrative over-head of 20% was $30. Therefore, CCSP cost wasestimated to be $3,660. There also were 5 homeassessment visits at $95.61 each, totaling $478.05.The estimated CCSP and assessment costs com-bined resulted in total of $4,138.05. When thesecosts are added to CCSP inpatient costs, the re-sults remained lower for CCSP ($13,103.20 vs$30,650.28; p =.041) (Table 3).

DiscussionThe study findings are encouraging for the devel-opment of care coordination and health counsel-ing programs. They suggest that such programscan enhance satisfaction with services and carequality while reducing inpatient care costs.

The participants for this evaluation were re-cruited as part of a Centers for Medicare andMedicaid demonstration and were Medicare eligi-ble. However, this type of partnership is novel,and government funding is not available cur-rently to support partnership services. Becausethe prospect of supporting such servicesthrough governmental auspices is a long-termproposition, we suggest that our findings may beapplicable to private pay populations in HHAsthat may be able to benefit from CCSP.

However, these results should be interpretedwith caution because the described pilot programhad limitations. It was conducted at a single site.Such evaluations often are constrained by the ho-mogeneity of the population. All but one of thedyads were Caucasian, and all were English speak-ing. Also, program costs may vary at other sites,and it may be difficult to generalize these findingsto communities with different resource levels.

Furthermore, the design was vulnerable to se-lection bias because patients were not randomlyassigned. The differences in health use and costmay vary from those found in this study if con-trols were used for severity of illness betweengroups. Also, only inpatient costs were collected.Including outpatient costs might diminish healthuse and cost differences. Still, even if these re-sults are partly attributable to unmeasured dif-ferences in illness severity, the magnitude of theinpatient effect suggests that further research onstrategic partnerships is warranted.

The health use and cost results described in thisreport correspond to findings reported in the litera-ture concerning programs that are telephone pa-tient-centered and whole-person orientated (e.g.,advanced medical home) (American College ofPhysicians, 2006). Studies of coordination programsusing telephone interventions have found large re-ductions (40-60%) in hospitalization and institution-alization rates (Cherry et al., 2002; Meyers et al.,2002). Furthermore, the described health use andcost results parallel similar findings reported from arecently concluded evaluation of a patient-centeredcare management program delivered by RNs(Sweeney et al., 2007). In this recent evaluation, in-


patient admissions were reduced by 38%, with costreductions of $18,599 per patient. The CCSP pro-gram delivery costs ($129) mirror those in a medicalhome program ($400) that emphasized a whole-per-son orientation in which costs were limited to a fewhundred dollars per patient (Palfrey et al., 2004).

Care coordination programs vary greatly inthe aspects of care they emphasize (Brown et al.,2007). The results from the described programand other programs cited in this report suggestthat programs with an emphasis on facilitatingcoping skills and adaptation to loss in seriouschronic illness may be associated with both im-proved quality and reduced resource use.

A clinically significant potential for CCSP wasidentified in interviews with clinicians. The clini-cians suggested CCSP as a resource for situationsin which payers require discharge from certifiedhome care but psychosocial and coping supportsare still needed. Furthermore, they observed thatfamilies’ ongoing contact with nursing supportsafter discharge increases the likelihood that re-certification of home care will be timely, thus im-proving the preventive aspects of home care.

Findings indicate that CCSP is a low-cost, sat-isfactory, clinically effective program that im-proves the use of dementia-relevant communityservices and may reduce costs without affectingthe percentage of deaths.

RecommendationHome healthcare agencies can explore partner-ships with telephone support programs in an ef-fort to offer continuity of care in chronic illnessby (1) creating a viable discharge resource forfamilies who need further assistance in managingillness but are no longer eligible for certifiedservices, (2) offering assessment visit services,and (3) increasing the likelihood of more timelyrecertification of patients who need homecare.

AcknowledgmentsWe wish to acknowledge Michael Schwabenbaur,PhD, for his assistance in critiquing the funding re-quest and helping conduct the project. We wouldalso like to thank Shari Longo, RN, Maria Seman,RN, and Nora Smith, RN, for providing the home

Table 3. Healthcare Use and Cost by Group

Group

Variable CCSP HC Difference df t χ2

(n = 36) (n = 113)

n P N P

Admissions 4 11% 84 74% 63.00% 1 45.137**

M SD M SD

IP LOS (days) 1 3.41 5.29 5.39 4.29 147 4.492**

IP LOS(weighted days)

1.26 3.98 5.29 5.39 4.03 147 4.139**

IP cost $10,372.53 41342.16 $30,650.28 41260.94 $20,277.75 147 2.567*

IP cost(weighted) $12,988.81 53553.07 $30,650.28 41260.94 $17,661.47 147 2.074*

IP cost(weighted with program costs)

$13,103.20 53553.07 $30,650.28 41260.94 $17,547.08 147 2.061*

*p < .05. **p < .001Note. IP = inpatient; LOS = length of stay.


healthcare partnership services throughout theproject.

Joseph B. Engelhardt, PhD, is Director of Train-ing, Care Support of America, Albany, New York.

Theresa Kisiel, NP, is Research Coordinator,Hamot Medical Center, Erie, Pennsylvania.

Jeremy Nicholson, MSW, is Data Analyst, CareSupport of America, Albany, New York.

Lori Mulichak, RN, is Nurse Clinician, CareSupport of America, Albany, New York

James DeMatteis, MD, is Physician, HamotMedical Center, Erie, Pennsylvania.

Daniel R. Tobin, MD, is Director, Care Supportof America, Albany, New York.

Address for correspondence: Joseph B. Engel-hardt ([email protected]).

J. Engelhardt, J. Nicholson, and D. Tobin are cur-rently affiliated with Care Support of America (CSA).CSA is developing care coordination and supportpartnerships as a commercial service to help familycaregivers manage chronic illness at home.

The contents of this article are in the public domain.

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Use of Community Services,Satisfaction of Family