17
Patient Education and Counseling, 15 (1990) 17-28 Elsevier Scientific
Publishers
Ireland
Ltd.
Effectiveness of a Hospital-Based Cooperative on Patients’ Functional Status and Utilization A. Judith Chwalow, Joyce Mamon, Engin Crosby, Salkever, Maureen Fahey and David M. Levine
Anthony
Care Model
J. Grieco,
David
Department of Health Policy and Management, The Johns Hopkins University School of Hygiene and Public Health, and the Division of Internal Medicine, School of Medicine, Baltimore, Maryland, in conjunction with the Cooperative Care Unit of New York University Medical Center, New York (USA) (Received (Accepted
July 14th, 1989) October 3Oth, 1989)
Abstract The primary objective of this study was to test the hypothesis that inpatient care which emphasized structured, patient education, self-care and social support from a care partner (the Cooperative Care Program) is a costeffective alternative to the more expensive staff-intensive, traditional hospital care; and that such care can be substituted without resulting in poorer outcomes with regard to subsequent health status or use of services. The effects of this program on patient and physician acceptance, patient knowledge and treatment and health status, were evaluated by means of an experimental design with comparable groups of patients assigned to experimental (cooperative care) or control (usual hospitalization) group status. Followup analyses of both groups of patients for a 12-month time period concluded that there A.J. Chwalow, RN,DrPH J. Mamon, PhD E. Crosby, PhD A.J. Grieco, MD D. Salkever, PhD M. Fahey, MLA D.M. Levine, MD,MPH,ScD
Correspondence to: David University Baltimore,
M. Levine, The Johns Hopkins School of Medicine, 1830 East Monument Street, MD 21205, USA.
0738-3991/90/$03.50 Published and Printed
0 1990 Elsevier Scientific in Ireland
Publishers
Ireland
were comparable and equally positive posthospitalization experiences, with greater than 90% of both groups of patients functioning well with respect to a series of measures of functional status. There was no evidence that Cooperative Care patients were re-hospitalized more often or needed more emergency, home care or other types of services. There was, on the other hand, evidence of the positive effect on patient understanding, adherence to treatment, satisfaction, and selfmanagement. Keywords: Cooperative Care; Social support; Functional status; Utilization patterns. Introduction The traditional inpatient acute hospital setting is organized primarily for intensive management of disease, but not well-suited for patient education leading to subsequent independent home self-management [l-3]. This approach is quite costly and may result in increased dependency of patients and lack of attaining full functional capacity subsequently. The primary research objective of this study was to test the hypothesis that an inpatient setting, which emphasized patient education, self-care, and social support from a care partner (the Cooperative Care Center), Ltd.
was a cost-effective alternative to the traditional hospital staff-intensive care. More specifically, the major hypothesis to be tested was that such cooperative care could be provided in a less costly, less medically intensive manner, without resulting in poorer health or functional status or increased utilization of services. The major independent variable to be evaluated was the New York University Cooperative Care Center Program (CCC), which is a unique and innovative organizational change in the delivery of acute care for inpatients with underlying chronic conditions [4-71. The Cooperative Care Center, which is a component of the New York University Hospital, is structured to be staffed with less medical personnel, but to provide more educational services. Its central feature is the presence of a family member or friend who acts as a “care partner” and lives in the patient’s home-like room during the hospitalization (described in more detail in the previous article in this collection). Several prior studies have noted improved care outcomes secondary to incorporation of the family in health care [8-lo]. All patients undergo an educational assessment by a “nurse educator” to identify teaching needs regarding the patient’s health problem(s), diagnostic procedures, and therapy, including diet, physical activity, and medications. The patient and care partner are educated by a multidisciplinary team including nurse-educators, nutritionists, pharmacists, social workers, and recreation therapists through group as well as individual sessions. Patients are educated to achieve self-management, including selecting food consistent with their prescribed diet, engaging in appropriate physical activity, taking responsibility for administering their medication, and addressing psychosocial needs. Thus, patients and care partners are educated to rehearse the behaviors they will need for long-term management. Health and functional status measures selected for evaluation were those identified as beneficial to the patient’s quality of life,
such as activities of daily living, instrumental activities of daily living, mobility, social communications, and lack of complications. Utilization of health services included: hospitalizations, emergency room visits, ambulatory visits, and telephone contacts with providers. In addition, intermediate outcomes measured were cognitive, affective and behavioral changes in patients and care partners such as knowledge of the disease and treatment processes, appropriate ahderence to treatment, including diet, physical activity, and medications. In order to investigate the effect of Cooperative Care, an experimental design with comparable groups of patients and their care partners assigned to experimental (cooperative care) or control (ususal hospitalization) status was selected. All patients were considered eligible for transfer, except those admitted to Psychiatry, Pediatrics, and Obstetrics, or patients with diabetes for whom control group status was deemed unethical because of the already demonstrated role of inpatient education. All other patients admitted to the New York University Hospital between 1981 and 1983 were screened using the four CCC admission criteria (see previous paper by Grieco in this collection). Screening took place within 48 h after admission for medical patients, and within 48 h after the procedure for surgical patients. Those who met all four criteria were invited to participate in the study, and virtually all patients agreed. Study patients were randomly assigned either to remain in the traditional setting (UH) or be transferred to Cooperative Care (CCC). Patients eligible for participation in the study, who were transferred by their physicians to the Cooperative Care Center, were assigned to the experimental group. For each patient assigned to the experimental group, a matched patient (on major study characteristics), who was eligible for transfer but remained at the University Hospital and was subsequently discharged from there, was assigned to the control group. If any patient
19
tacts. The number of unsuccessful contacts or interviews between the experimental and control groups were examined by patient and disease characteristics in order to test for significant differences. Table II presents a profile of patients recruited into the study. There were no significant differences on major sociodemographic or disease characteristics between those persons interviewed successfully and those not interviewed. The results of these analyses suggest that there was no systematic bias in the sample accrual. Comparisons of sociodemographic and clinical characteristics between respondents in the two groups at 6 months demonstrated that there was no systematic attrition bias. Those completing the 6-month interview had the same distributions on clinical and sociodemographic variables as those completing the first, l-month interview. Analysis of respondents to the 9- and 1Zmonth follow-up surveys also indicated there were no differences on major clinical and sociodemographic variables when compared to those completing the first l-month interview. The emphasis of this paper is on the first 6 months post-discharge, as this was the time period when differences attributable to the intervention were most likely to occur. The 9- and 12-month postdischarge data were used to examine possible longer term effects of the intervention. However, less emphasis is placed on the latter data given the lower response rates.
was re-admitted to New York University Hospital within 6 months of the starting date for the study, the hospital agreed that the patient would receive the same model of inpatient care. Cooperative Care patients could also enter by direct admission, with the same criteria and methodology applied to assignment. Sources of data for this study included: a screening interview; a l-month and 6-month post-hospital discharge telephone interview with patient and care partner; a g-month and 1Zmonth mailed patient survey; and Blue Cross/Blue Shield of Greater New York and Medicare records. These sources provided data on pre-hospitalization, hospitalization, and post-hospitalization characteristics which included patient and care partner understanding, compliance with treatment, self-management, perceived social support, as well as patient health status and utilization of health services. Sample characteristics Sample recruitment and response rates Table I displays the number of individuals recruited into the study and successfully interviewed 1 month post index hospitalization and the number of interviews completed at 6, 9 and 12 month follow-up by Experimental and Control groups. At 6 months, there was an 80% completion rate for interview conTable I.
Sample response
rates: 1 month,
6 months,
12 months
post-index
hospitalization.
No. of successful interview com-
Six-month number of interviews completed second follcw-
pletions at first follow-up
UP”
N
N
%b
VOO)’
N
%
Vo)
N
%
Vo)
159
84
(56)
102
53.7
(30)
77
40.5
(27)
144
80
(48)
85
47.2
(38)
69
38.3
(23)
Vs)
Experimental 190
Nine-month completed
number
of interviews
Twelve-month number interviews completed
of
(n = 283)
(67)
Control (n = 300) 180 (60)
‘The criteria for successful completion is a complete patient and/or care partner questionnaire. bThe completion rate of the second follow-up interview is the percentage of completed patient completed patient and care partner questionnaires at the first follow-up period.
Patient Education and Counseling, 15 (1990) 17-28 Elsevier Scientific
Publishers
Ireland
Ltd.
Effectiveness of a Hospital-Based Cooperative on Patients’ Functional Status and Utilization A. Judith Chwalow, Joyce Mamon, Engin Crosby, Salkever, Maureen Fahey and David M. Levine
Anthony
Care Model
J. Grieco,
David
Department of Health Policy and Management, The Johns Hopkins University School of Hygiene and Public Health, and the Division of Internal Medicine, School of Medicine, Baltimore, Maryland, in conjunction with the Cooperative Care Unit of New York University Medical Center, New York (USA) (Received (Accepted
July 14th, 1989) October 3Oth, 1989)
Abstract The primary objective of this study was to test the hypothesis that inpatient care which emphasized structured, patient education, self-care and social support from a care partner (the Cooperative Care Program) is a costeffective alternative to the more expensive staff-intensive, traditional hospital care; and that such care can be substituted without resulting in poorer outcomes with regard to subsequent health status or use of services. The effects of this program on patient and physician acceptance, patient knowledge and treatment and health status, were evaluated by means of an experimental design with comparable groups of patients assigned to experimental (cooperative care) or control (usual hospitalization) group status. Followup analyses of both groups of patients for a 12-month time period concluded that there A.J. Chwalow, RN,DrPH J. Mamon, PhD E. Crosby, PhD A.J. Grieco, MD D. Salkever, PhD M. Fahey, MLA D.M. Levine, MD,MPH,ScD
Correspondence to: David University Baltimore,
M. Levine, The Johns Hopkins School of Medicine, 1830 East Monument Street, MD 21205, USA.
0738-3991/90/$03.50 Published and Printed
0 1990 Elsevier Scientific in Ireland
Publishers
Ireland
were comparable and equally positive posthospitalization experiences, with greater than 90% of both groups of patients functioning well with respect to a series of measures of functional status. There was no evidence that Cooperative Care patients were re-hospitalized more often or needed more emergency, home care or other types of services. There was, on the other hand, evidence of the positive effect on patient understanding, adherence to treatment, satisfaction, and selfmanagement. Keywords: Cooperative Care; Social support; Functional status; Utilization patterns. Introduction The traditional inpatient acute hospital setting is organized primarily for intensive management of disease, but not well-suited for patient education leading to subsequent independent home self-management [l-3]. This approach is quite costly and may result in increased dependency of patients and lack of attaining full functional capacity subsequently. The primary research objective of this study was to test the hypothesis that an inpatient setting, which emphasized patient education, self-care, and social support from a care partner (the Cooperative Care Center), Ltd.
was a cost-effective alternative to the traditional hospital staff-intensive care. More specifically, the major hypothesis to be tested was that such cooperative care could be provided in a less costly, less medically intensive manner, without resulting in poorer health or functional status or increased utilization of services. The major independent variable to be evaluated was the New York University Cooperative Care Center Program (CCC), which is a unique and innovative organizational change in the delivery of acute care for inpatients with underlying chronic conditions [4-71. The Cooperative Care Center, which is a component of the New York University Hospital, is structured to be staffed with less medical personnel, but to provide more educational services. Its central feature is the presence of a family member or friend who acts as a “care partner” and lives in the patient’s home-like room during the hospitalization (described in more detail in the previous article in this collection). Several prior studies have noted improved care outcomes secondary to incorporation of the family in health care [8-lo]. All patients undergo an educational assessment by a “nurse educator” to identify teaching needs regarding the patient’s health problem(s), diagnostic procedures, and therapy, including diet, physical activity, and medications. The patient and care partner are educated by a multidisciplinary team including nurse-educators, nutritionists, pharmacists, social workers, and recreation therapists through group as well as individual sessions. Patients are educated to achieve self-management, including selecting food consistent with their prescribed diet, engaging in appropriate physical activity, taking responsibility for administering their medication, and addressing psychosocial needs. Thus, patients and care partners are educated to rehearse the behaviors they will need for long-term management. Health and functional status measures selected for evaluation were those identified as beneficial to the patient’s quality of life,
such as activities of daily living, instrumental activities of daily living, mobility, social communications, and lack of complications. Utilization of health services included: hospitalizations, emergency room visits, ambulatory visits, and telephone contacts with providers. In addition, intermediate outcomes measured were cognitive, affective and behavioral changes in patients and care partners such as knowledge of the disease and treatment processes, appropriate ahderence to treatment, including diet, physical activity, and medications. In order to investigate the effect of Cooperative Care, an experimental design with comparable groups of patients and their care partners assigned to experimental (cooperative care) or control (ususal hospitalization) status was selected. All patients were considered eligible for transfer, except those admitted to Psychiatry, Pediatrics, and Obstetrics, or patients with diabetes for whom control group status was deemed unethical because of the already demonstrated role of inpatient education. All other patients admitted to the New York University Hospital between 1981 and 1983 were screened using the four CCC admission criteria (see previous paper by Grieco in this collection). Screening took place within 48 h after admission for medical patients, and within 48 h after the procedure for surgical patients. Those who met all four criteria were invited to participate in the study, and virtually all patients agreed. Study patients were randomly assigned either to remain in the traditional setting (UH) or be transferred to Cooperative Care (CCC). Patients eligible for participation in the study, who were transferred by their physicians to the Cooperative Care Center, were assigned to the experimental group. For each patient assigned to the experimental group, a matched patient (on major study characteristics), who was eligible for transfer but remained at the University Hospital and was subsequently discharged from there, was assigned to the control group. If any patient
19
tacts. The number of unsuccessful contacts or interviews between the experimental and control groups were examined by patient and disease characteristics in order to test for significant differences. Table II presents a profile of patients recruited into the study. There were no significant differences on major sociodemographic or disease characteristics between those persons interviewed successfully and those not interviewed. The results of these analyses suggest that there was no systematic bias in the sample accrual. Comparisons of sociodemographic and clinical characteristics between respondents in the two groups at 6 months demonstrated that there was no systematic attrition bias. Those completing the 6-month interview had the same distributions on clinical and sociodemographic variables as those completing the first, l-month interview. Analysis of respondents to the 9- and 1Zmonth follow-up surveys also indicated there were no differences on major clinical and sociodemographic variables when compared to those completing the first l-month interview. The emphasis of this paper is on the first 6 months post-discharge, as this was the time period when differences attributable to the intervention were most likely to occur. The 9- and 12-month postdischarge data were used to examine possible longer term effects of the intervention. However, less emphasis is placed on the latter data given the lower response rates.
was re-admitted to New York University Hospital within 6 months of the starting date for the study, the hospital agreed that the patient would receive the same model of inpatient care. Cooperative Care patients could also enter by direct admission, with the same criteria and methodology applied to assignment. Sources of data for this study included: a screening interview; a l-month and 6-month post-hospital discharge telephone interview with patient and care partner; a g-month and 1Zmonth mailed patient survey; and Blue Cross/Blue Shield of Greater New York and Medicare records. These sources provided data on pre-hospitalization, hospitalization, and post-hospitalization characteristics which included patient and care partner understanding, compliance with treatment, self-management, perceived social support, as well as patient health status and utilization of health services. Sample characteristics Sample recruitment and response rates Table I displays the number of individuals recruited into the study and successfully interviewed 1 month post index hospitalization and the number of interviews completed at 6, 9 and 12 month follow-up by Experimental and Control groups. At 6 months, there was an 80% completion rate for interview conTable I.
Sample response
rates: 1 month,
6 months,
12 months
post-index
hospitalization.
No. of successful interview com-
Six-month number of interviews completed second follcw-
pletions at first follow-up
UP”
N
N
%b
VOO)’
N
%
Vo)
N
%
Vo)
159
84
(56)
102
53.7
(30)
77
40.5
(27)
144
80
(48)
85
47.2
(38)
69
38.3
(23)
Vs)
Experimental 190
Nine-month completed
number
of interviews
Twelve-month number interviews completed
of
(n = 283)
(67)
Control (n = 300) 180 (60)
‘The criteria for successful completion is a complete patient and/or care partner questionnaire. bThe completion rate of the second follow-up interview is the percentage of completed patient completed patient and care partner questionnaires at the first follow-up period.
