Community-Based Care Model for High-Risk Adults with Severe Disabilities

TitleCommunity-Based Care Model for High-Risk Adults with Severe Disabilities
Publication TypeJournal Article
Year of Publication2007
AuthorsNaylor, Mary D., Veronica R. Hill-Milbourne, Sefi R. Knoble, Keith M. Robinson, Kathryn H. Bowles, and Greg Maislin
JournalHome Health Care Management & Practice
AbstractObjective: Evaluate the effectiveness of a home-based intervention for adults with serious physical disabilities at high risk for poor health outcomes. Design: A pretest/post-test design; content analysis of case studies. Setting: Five-county Philadelphia metropolitan area. Patients and Other Participants: Forty-nine community-dwelling adults aged 20—55. Intervention: Six-month comprehensive care management intervention implemented by Advanced Practice Nurses (APNs) focused on improvement of functional status or prevention of functional decline; management of health problems; and enhancement of self-direction of care by subjects and caregivers. Main Outcome Measures: Functional status; total hospitalizations, emergency department (ED) and acute care physician visits; symptom management; depression; quality of life; and satisfaction with care. Results: Between baseline assessment and nine months post-APN intervention, functional status improved (mean = 33.42 → 24.97, p = 0.014). There was a trend toward reductions in average hospitalization rate from 1.10 at baseline to 0.68 nine months post-APN intervention and ED rates from 0.90 to 0.50. Acute care visits to physicians increased from 0.52 to 0.95 from baseline to nine months post-APN intervention. The use of home health aides (mean = 2.72 → 1.37, p = 0.008) and physical therapists (mean = 1.16 → 0.42, p = 0.001) also decreased from baseline to nine months post-APN intervention. Facilitators and barriers to care are identified. Conclusions: Findings suggest potential benefit of a comprehensive, individualized intervention coordinated by APNs in improving health and functional outcomes and decreasing the use of