A Mixed-Methods Evaluation of a Nurse-Led Community-Based Health Home for Ethnically Diverse Older Adults With Multimorbidity in the Adult Day Health Setting

Sadarangani T, Missaelides L, Eilertsen E, Jaganathan H, Wu B
Source: Policy Polit Nurs Pract
Publication Year: 2019
Patient Need Addressed: Care Coordination/Management, Chronic Conditions
Demographic Group: Adult
Intervention Type: Service redesign
Study Design: Mixed-Methods
Type of Literature: White

Multimorbidity affects 75% of older adults (aged 65 years and older) in the United States and increases risk of poor medical outcomes, especially among the poor and underserved. The creation of a Medicaid option allowing states to establish health homes under the Affordable Care Act was intended to enhance coordinated care for Medicaid beneficiaries with multimorbidity. The Community-Based Health Home (CBHH) model uses the infrastructure of the Adult Day Health Center (ADHC) to serve as a health home to improve outcomes for medically complex vulnerable adults. Between 2017 and 2018, we used a sequential explanatory mixed-methods approach to (a) quantitatively examine changes in depression, fall risk, loneliness, cognitive function, nutritional risk, pain classification, and healthcare utilization over the course of 12 months in the program and (b) qualitatively explore the perspectives of key stakeholders (registered nurse navigators, participants, ADHC administrators, and caregivers) to identify the most effective components of CBHH. Using data integration techniques, we identified components of CBHH that were most likely driving outcomes. After 12 months in CBHH, our racially diverse sample (N = 126), experienced statistically significant (p < .05) reductions in loneliness, depression, nutritional risk, poorly controlled pain, and emergency department utilization. Stakeholders who were interviewed (n = 40) attributed positive changes to early clinical intervention by the registered nurse navigators, communication with providers across settings, and a focus on social determinants of health, in conjunction with social stimulation and engagement provided by the ADHC. CBHH positions the ADHC as the locus of an effective health home site and is associated with favorable results. CBHH also demonstrates the unique capacity and skill of registered nurses in integrating health and social services across community settings. Continued exploration of CBHH among diverse populations with multimorbidity is warranted.

Insights Results

Overview of model

  • The Community-Based Health Home (CBHH) uses infrastructure of the Adult Day Health Center (ADHC) to serve as a health home to improve outcomes for medically complex vulnerable adults
  • ADHC are increasing in number across the US and serve community-dwelling chronically ill and functionally impaired individuals, many of whom are below the federal poverty thresholds. Community-based centers are designed to provide both a socially supportive environment and health services to adults who require supervised care and health services during the day
  • The CBHH model is the first in the nation to use the ADHC as a health home for medically complex vulnerable adults
  • Model eligibility criteria: 1) 18 years or older and assessed to qualify for community-based adult services; 2) Chronic physical or mental health or cognitive condition that requires ongoing medical attention AND/OR psychosocial conditions that make the person vulnerable to fragmented systems of care AND/OR recent institutionalization; 3) Events that trigger the need for increased support from RN or social worker; and 4) Be assessed as being able to benefit by additional intensive support from the CBHH through targeted goal-focused interventions to be carried out by the nurse navigator in conjunction with the care team
  • Key components of CBHH model: 1) Utilize interdisciplinary team services that are individualized and person-centered (e.g., nursing surveillance); 2) Comprehensive needs assessment of patients; 3) Delivery of transitional care support, patient activation, and education to advance health literacy; and 4) Use of nurse navigators to assess patients and address any emerging crises with a high-risk caseload of patients. Navigators are trained in motivational interviewing which helps participants identify and change behaviors; and 5) Regular project team meetings and trainings related to key acquisition of knowledge and skills required for the project
  • Between 2017 and 2018, authors used a sequential explanatory mixed-methods approach to 1) Quantitively examine changes in depression (revised GDS), fall risk (CDC STEADI Fall Risk Assessment Program), loneliness (R-UCLA Loneliness Scale), cognitive function (Orientation Memory Concentration Tool), nutritional risk (DETERMINE Checklist), pain classification (Modified Universal Pain Assessment Tool), quality of life (Revised DQoL Self-Esteem subscale) and healthcare utilization over the course of 12 months in the program and qualitatively explore perspectives of 40 key stakeholders (registered nurse navigators, participants, ADHC administrators, and caregivers) to identify most effective components of CBHH


    • 12 participating sites were located in California, 2 in rural communities and 10 in major metropolitan areas
    • Proportion of participants at high nutritional risk decreased from 48.6% to 35.1%, while those with moderate nutritional risk increased from 39.2% to 51.4%
    • Proportion reporting good quality of life increased from 53.1% to 62.5%
    • Proportion of those who reported an emergency department visit in the last 12 months decreased from 48.4% to 38.4% and the proportion who reported hospital admission decreased from 32.5% to 27.8%
    • Themes from qualitative interviews: 1) Identification of high-risk patients; 2) Early clinical intervention; 3) Improved chronic disease management; 4) Sharing clinical data with providers; 5) Focus on social determinants of health (e.g., ensuring patients have access to food and nutrition through governmental programs; 6) Support for caregivers; 7) advocacy in the clinical setting (e.g., insisting on reevaluation or further treatment when a clinical issue fails to resolve); 8) Presence across multiple (e.g., meeting participant at home or in hospital; and 9) Identifying patient-centered goals
    • Participants also acknowledged the value of ADHC in reducing social isolation through social stimulation, building meaningful relationships, and supporting productive engagement
      Key Takeaways
    • Results suggest that with the addition of the nurse navigator, the ADHC may be able to improve health outcomes for vulnerable seniors by leveraging its ability to surveil participants and intervene on their behalf to prevent adverse outcomes before they arise
    • Embedding the nurse navigator into the ADHC, commonly overlooked as an effective and desirable care site, to be part of the care continuum