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Hypertension is the most common chronic disease in South Korea, affecting 28% of people older than 30 years and 56% of the elderly, as reported in 2005 (Korea Institute for Health and Social Affairs [KIHSA], 2006). Hypertension is also the major risk factor for cardiovascular and cerebrovascular diseases, which are the second and third leading causes of death in Korea (Korea National Statistical Office, 2009). Compared with other chronic diseases, hypertension is relatively easy to manage, but the compliance rate is not high. Hypertension has asymptomatic characteristics, and treatment is generally of a lifelong nature. These are the major key factors that contribute to poor adherence (Haynes, McKibbon, & Kanai, 1996; Krousel-Wood, Thomas, Muntner, & Morisky, 2004).
Improving hypertension care has been a priority issue in Korea over the past several years. Beginning in 2002, the National Health Insurance Corporation (NHIC), which administers the health insurance of the country, has implemented nationwide projects for hypertension, diabetes, cerebrovascular disease, and rheumatic disease for the individuals who enrolled in the NHIC in order to reduce health insurance costs. On the other hand, low-income patients who enrolled in the tax-based Medical Aid Program can receive health services provided by the public health center in Korea. Offering the qualified chronic diseases management program for these underserved populations has become one of the major concerns in public health.
Long-term management of hypertension, which is more prevalent in socioeconomically disadvantaged populations, presents challenges for healthcare providers in community health centers (Baumann, Chang, & Hoebeke, 2002). Particularly low-income patients are likely to seek medical care only when the disease has progressed to the advanced stages and often give up treatment due to economic constraints and lack of support for changing their health conditions. Difficulties in accessing free medications, inadequate self-management behaviors, and lack of healthcare visits for those of lower socioeconomic status were factors associated with medication non-adherence which is an important barrier in hypertension control (Martin et al., 2010). Thus, there is a need for more effective intervention that promotes a healthy lifestyle if health disparities in low-income populations with chronic conditions are to be reduced. One approach to provide high-quality care for a financially restricted patient is to use a visiting nurse-driven community-based case management (CBCM) service.
Case management is an integrated service mechanism that involves a process of case finding, assessment, care planning, service providing, monitoring, and evaluation (O'Hare & Terry, 1991). The goals of nursing case management are the provision of quality health care along “continuum of care services” from illness to wellness, enhancement of the client's quality of life, and cost containment (Hammer, 2001; O'Hare & Terry, 1991). Hammer (2001) stressed that a CBCM program was important, as well as the acute care in the hospital, because many patients living in the community did not have adequate knowledge about health services and resources. Low-income chronic patients living at home were particularly vulnerable to lacking health information and bearing the cost burden of medical services. To meet the needs of obtaining health information and lessening the cost burden of health services for this group of people, as well to enhance their self-management abilities of chronic health conditions such as hypertension, CBCM can be one of the approaches.
Community-based case management programs generally provide for the long term, for clients with hypertension; this program was designed to promote a healthy lifestyle, improve treatment compliance, and reduce costs (Kim et al., 2003). Evidence supports the effectiveness and economic efficiency of case management for people with chronic diseases (Norris et al., 2002; Rudd et al., 2004). Allen et al. (2011) also reported that a community outreach comprehensive program delivered by nurse practitioner and community health worker was more effective than usual care. Patients in the intervention, which included tailored educational and behavioral counseling for lifestyle modification, obtained significant improvement in blood pressure (BP) and perceptions of their chronic illness care.
In the present study, we examined whether visiting nurse-driven CBCM focusing on self-management could be successfully implemented and whether it would improve BP and health behavior outcomes in low-income patients with hypertension who are not enrolled in the NHIC.
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We examined a visiting nurse-driven CBCM program targeting BP reduction, lifestyle modification, and improvement of knowledge on hypertension for low-income persons with hypertension who were enrolled in a public health center. As anticipated, after the CBCM program, the patients showed improvement in BP control and level of hypertension self-management and knowledge. These results shared similarities with various studies (Lee, 2004; Park, 2003). The study of Lu et al. (2005), in which family doctors provided guidance on the CBCM program, showed that the rate of hypertension under control had increased from 50.4% to 69.8%, whereas in our study it increased from 0% to 72.7%. This result implied that home visit and tailored intensive management was effective for newly diagnosed hypertensive patients. Among the many components of a comprehensive health and disease management program, home visits and intensive management for the patient may be key points. Especially for newly diagnosed hypertension patients, encouraging adherence to medication and lifestyle modification should be a major opportunity for a dramatic reduction in BP.
Education alone is not associated with large net reductions in BP. Community-based health centers should have an organized system for regular review and follow up of hypertensive patients to improve control of BP (Glynn, Murphy, Smith, Schroeder, & Fahey, 2010). In our study, according to the organized screening and intensive management guidelines of the NHIC, the visiting nurse, as a case manager, could organize screening of hypertensive patients and stringently deliver the necessary care.
In this study, the patients were vulnerable because they were mostly older people, living alone, with low incomes. Therefore, the services of the case manager could be essential for improving their health outcomes. The case manager's roles included assessment, planning, coordinating, monitoring, and evaluation (Bryan, Dickenson, Fleming, Gholston, & Thompson, 1994). As described in the study of Chan, Mackenzie, Ng, and Leung (2000), these functions of the case manager are considered important factors that affect the outcome of care. Through frequent telephone contact and home visits, the patients may develop trust in the case manager, thereby increasing their motivation to manage hypertension. The human involvement and intensity of care provided by the case manager may be one of the keys to patient improvement (Chan et al., 2000).
In our study, the visiting nurses educated patients about measuring and recording their BP at every visit; this may improve estimates of BP. Self-monitoring of BP at home is a reliable alternative to office measurement (Rudd et al., 2004). This may help improve awareness, increase BP reduction, and result in better BP control than that achieved through BP monitoring in the healthcare system (Cappuccio, Kerry, Forbes, & Donald, 2004).
From pretest to post-test, the mean score in each of the dimensions of lifestyle management showed a statistically significant improvement. Self-management for a modified lifestyle is also important for patients to live successfully in the community. According to the JNC 7, lifestyle modifications such as weight reduction, low-salt diet, aerobic physical activity, moderate alcohol consumption, and a diet rich in fruits, vegetables, and low-fat dairy products are essential to reduce BP.
The level of knowledge on hypertension improved after the CBCM program, as evidenced by statements such as “severe hypertension can result in cardiac, renal, or cerebral complications” and “hypertension drugs can be stopped”. As Clark, Curran, and Noji (2000) noted, assessment of the patient's knowledge of hypertension and its effects, awareness of drug therapy, and lifestyle modification are the responsibilities of public health nurses. This study further suggests that CBCM should be accompanied by health education regarding the patient's lifestyle, basic knowledge of hypertension, and the correct measurement of BP.
Because the number of older persons in the low-income bracket without family is increasing, the role of public health nurses might be essential for managing chronic diseases as well as hypertension in the community.
This study has several limitations. Because it was not feasible to use a control group in this study, the reasons for the improvements demonstrated cannot be conclusively determined. Strictly speaking, it is difficult to judge whether the change was due to intervention or time-dependent change. In addition, this study measured the outcome only before and after the intervention; thus, the results cannot show the long-term effects of CBCM. A study measuring sustained long-term improvement is required. In addition to lack of the subject's profile, such as educational level, this study has threats such as interaction of selection and treatment, and interaction of setting and treatment. Another important limitation is the relatively small sample size, which means that the data of the sample were not representative of the low-income hypertension population. Therefore, the generalization of these findings to other populations may not be appropriate. In addition, the self-assessment method may have overestimated the participants' level of self-management. In the future, both subjective and objective assessments should be used for improving the level of self-management.
This study serves as a baseline for visiting nurse-driven CBCM for low-income patients with hypertension. These findings suggest that visiting nurse-driven CBCM targeting the self-management of BP can foster improved BP control for hypertension patients in low-income populations.