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Keywords:

  • chronic illness;
  • community nursing;
  • hypertension;
  • low-income patients

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Measures
  6. Results
  7. Discussion
  8. Acknowledgments
  9. Conflict of interest
  10. References

Aim

To assess the effects of a visiting nurse-driven community-based case management program for low-income adults with hypertension.

Methods

This single group pretest–post-test study included 22 newly registered low-income adult patients with hypertension in a public health center in Seoul. Visiting nurses delivered a case management program for 2–8 months. Pretest and post-test measurements of blood pressure (BP), knowledge level, and self-management level in terms of diet, lifestyle, physical activity, and medication were obtained.

Results

The visiting nurse-driven case management was effective in reducing the BP level and improving the knowledge and self-management level of the low-income adults with hypertension in the community.

Conclusion

This study serves as a baseline for visiting nurse-driven case management for low-income patients with hypertension. Its findings suggest that visiting nurse-driven case management targeting the self management of BP can foster improved BP control for newly diagnosed hypertensive patients in low-income populations.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Measures
  6. Results
  7. Discussion
  8. Acknowledgments
  9. Conflict of interest
  10. References

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.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Measures
  6. Results
  7. Discussion
  8. Acknowledgments
  9. Conflict of interest
  10. References

Design and sample

A single group pretest–post-test design was conducted to identify the effectiveness of the CBCM for low-income adults with hypertension in a public health center. The public health center was located in a region with a population of 400,000 residents in Seoul.

All newly registered low-income adults with hypertension were selected from the total client pool of 1,547 hypertension patients listed on the database in a public health center. For the sample subjects, chart reviews were conducted to confirm the diagnosis of hypertension and that they were a member of a low-income family. The subjects were chosen for the study based on the following criteria: (i) they were aged 30 years or older; (ii) they were newly diagnosed with hypertension according to the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines (Chobain et al., 2003), according to which a systolic BP of 140 mmHg or higher or a diastolic BP of 90 mmHg or higher signifies hypertension, or they were taking antihypertensive agents; (iii) they were ranked in the lowest 50% of the population in terms of level of health insurance (KMHWF, 2006); and (iv) their family income was below 120% of the minimum living costs (KMHWF, 2006). Then, the nurses visited the clients' homes and investigated the need for a home visit based on the guideline of the public health center. Twenty-four hypertensive clients who met the selection criteria were selected and asked to participate. All agreed, and after completion of the CBCM program, the number of final participants was 22. The two participants were excluded because there were several data missing (Fig. 1).

figure

Figure 1. Flowchart of sampling procedure. CBCM, community-based case management.

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Study procedure

The study was approved by the director of the public health center, which was the usual accepted practice. The researcher explained the purpose and procedures of the study to the visiting nurses and requested their participation. All 15 visiting nurses participated voluntarily in the study and provided informed written consent.

A protocol in which the process of hypertension case management was documented and nursing records for home visits were also co-developed by the researchers and the nurses in the public health center. Four workshops and monthly conferences were conducted for this purpose.

Visiting nurses explained the aim and procedures of the study to hypertensive clients and asked them to participate. The nurses stressed that participation in the study was voluntary and that the clients could cease the participation whenever they wanted. All 24 patients participated voluntarily in the study and provided informed written consent. Actual care practice through home visits and phone contact was performed for 2 months, along with ongoing evaluation and re-planning accompanied this process.

The patients completed assessments at baseline and end of the CBCM program, over a period of 2–8 months. The duration of the CBCM program varied according to the patient's BP control, with 8 months being the longest duration. When the patient's BP was within the normal range or after 8 months, his/her CBCM program ended. Baseline and follow-up assessments were completed by the visiting nurses who had been directly responsible for the patient's care. Resting BP was measured in a seated position in both arms, and the average of the two measurements was used.

CBCM program

A CBCM program was modified by researchers based on the NHIC case management program. The NHIC case management program consisted of three home visits and two telephone contacts over 10 weeks and ending 10 weeks after the starting point, while the CBCM program consisted basically of six home visits and two telephone contacts and ended based on the patient's accomplishment of BP control. The overall goal of this program was to improve hypertension self-management and BP control in hypertension patients enrolled in public healthcare settings. Appropriate BP goals were defined according to the JNC 7 guidelines as less than 140/90 mmHg for those with hypertension. CBCM program comprised the following five steps: (i) selection of the client; (ii) need for assessment through home visiting; (iii) listing the problem and establishing the care plan; (iv) providing planned care through home visiting or telephone contact; and (v) evaluation through home visiting (Fig. 2).

figure

Figure 2. Process of hypertension case management program. BP, blood pressure.

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Each visiting nurse visited one to two patients during the study period depending on the patient's accomplishment of BP control through the case management service. During the first home visit, visiting nurses performed needs assessment and taught the patient how to check their BP using a home sphygmomanometer. The needs assessment included the patient's symptoms experienced during the last month, whether they had visited a physician for periodic advice and taken medications for BP control, whether they possessed a home sphygmomanometer, hypertension knowledge, and level of self-confidence in managing hypertension. In addition, individually tailored intervention contents included teaching and counseling about symptom management and lifestyle changes were planned by nurses according to the patient's health problems based on initial evaluation of needs assessment in each patient. Problem list, the priority, and objectives for each patient were established through reviewing the evaluation data and communication between nurse and patient. Visiting nurses implemented plan through home visiting or telephone contact and checked patient's BP at each time. Furthermore, they utilized the standard education material regarding understanding of hypertension, measurement of BP, exercise and diet, smoking and drinking, taking medications, and stress management to provide strategies for patients' self-management during home visits. For the program evaluation, home visiting nurses measured hypertension knowledge and level of self-confidence to manage hypertension and checked patient's BP in the last visit.

Measures

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Measures
  6. Results
  7. Discussion
  8. Acknowledgments
  9. Conflict of interest
  10. References

Hypertension knowledge

Lee's tool (1994) was used to assess the patient's hypertension knowledge. This comprised a 10 item scale designed for use with hypertension. Ten questions were asked concerning knowledge of the basic understanding of hypertension, risk factors of hypertension, signs and symptoms, complications, lifestyle changes for hypertension management, and medication. The knowledge score was determined by calculating the number of correct responses to these 10 questions. Lee (1994) reported that Cronbach's alpha of reliability was 0.67, whereas this value was 0.79 in the present study.

Hypertension self-management

A hypertension self-management instrument was developed by researchers and reviewed by four public health nurses. The scale, which contained 15 items, was designed to measure the patient's lifestyle, physical activity, diet, and medication. The lifestyle category includes five questions regarding regular evaluation of bodyweight, regular evaluation of BP, smoking, alcohol consumption, and the level of stress. The physical activity category had two questions regarding regular exercise and physical overwork. The diet category had six questions regarding regular meals, salt intake, sugar intake, fatty food intake, vegetable and fruit intake, and regulation of the amount of food eaten. The medication category had two questions concerning medication adherence and understanding the mechanism of action of antihypertensive drugs. Each response could be evaluated using a 3 point Likert scale. Higher scores indicated higher hypertension self-management.

Analytic strategy

Descriptive statistics were used to define the subject's demographic information. The χ2-test and paired sample Student's t-test were used to examine the changes in BP levels before and after the CBCM program. The knowledge scores on hypertension before and after the CBCM program were measured in terms of frequency and percentage. The changes in hypertension self-management levels before and after the CBCM program were assessed using the paired sample Student's t-test. The significance level was set at P < 0.05. All data were analyzed using SPSS ver. 12.0 (SPSS, Chicago, IL, USA).

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Measures
  6. Results
  7. Discussion
  8. Acknowledgments
  9. Conflict of interest
  10. References

Demographic profiles

Most patients were more than 65 years old (86.4%) and 77.3% were women. Fifty-nine percent of the patients were living alone without family or a spouse. Forty-five percent of the patients received the CBCM program for 5–6 months, and 36.4%, 9.1%, and 9.1% received this program for 3–4, 7–8, and 2 months, respectively.

Changes in BP

Table 1 shows the BP before and after the CBCM program. Before undergoing the CBCM program, 59.1% of the patients had stage 3 hypertension (i.e. systolic BP ≥160 mmHg or diastolic BP ≥100 mmHg), and 40.9% had stage 2 hypertension (i.e. systolic BP 140–159 mmHg or diastolic BP 90–99 mmHg). At the end of the CBCM program, 72.7% of the patients were in the therapeutic range (i.e. BP <140/90 mmHg). However, 27.3% of the patients still had stage 2 hypertension. The mean systolic BP decreased from 159.3 to 125.0 mmHg and this change was statistically significant (t = 8.43, P = < 0.001). The mean diastolic BP decreased from 93.3 to 78.4 mmHg and this change was statistically significant (t = 4.75, P = < 0.001).

Table 1. BP levels before and after CBCM (n = 22)
BP levelsN (%)χ2 or tP
Before CBCMAfter CBCM
  1. Comparisons were done by χ2-test and paired sample Student's t-test. P < 0.05. BP, blood pressure; CBCM, community-based case management; SD, standard deviation.

<140/900 (0.0)16 (72.7)29.60<0.001
140–159/90–999 (40.9)6 (27.3)
≥160/10013 (59.1)0 (0.0)
Mean (SD) systolic BP159.3 (18.0)125.0 (9.9)8.43<0.001
Mean (SD) diastolic BP93.3 (12.8)78.4 (6.5)4.75<0.001

Changes in hypertension knowledge

The exact changes in the proportion of patients answering questions about hypertension are shown in Table 2. Most patients responded correctly after undergoing the CBCM program. All patients (100%) correctly stated after the CBCM program that: (i) BP is not always consistent; (ii) severe hypertension can result in cardiac, renal, or cerebral complications; (iii) regular physical activity helps to control hypertension; and (iv) a low-sodium diet is important for controlling hypertension. Before the program, these correct responses were provided by 54.5%, 40.9%, 72.7%, and 68.2% of the patients, respectively. The numbers of patients who correctly stated that hypertension has a genetic factor increased from 40.9% before the CBCM program to 95.5% after this program. There was also an increase in the number of patients who correctly stated that once hypertension is controlled, drugs can be stopped, from 18.2% to 95.5%. Before the CBCM program, only 9.1% of the patients disagreed with the statement that hypertension always has the symptom of dizziness or headache; this percentage increased to 72.7% after the program. The percentage of patients who were aware that psychological distress is an aggravating factor of hypertension increased to 86% after the CBCM program, from 59.1% before. Similarly, there was an increase in the number of patients stating that weight reduction helps to control hypertension, from 45.5% to 90.9%, and that hypertension is associated with the overconsumption of alcohol and smoking, from 59.1% to 90.9%.

Table 2. Score changes in hypertension knowledge before and after CBCM (n = 22)
ItemsCorrect answerCorrect answer, N (%)
Before CBCMAfter CBCM
  1. CBCM, community-based case management.

Blood pressure is always consistent.No12 (54.5)22 (100.0)
Hypertension has a genetic factor.Yes9 (40.9)21 (95.5)
Psychological distress is an aggravating factor of hypertension.Yes13 (59.1)19 (86.4)
The person with hypertension always has a symptom of dizziness or headache.No2 (9.1)16 (72.7)
Severe hypertension can result in cardiac, renal, or cerebral complications.Yes9 (40.9)22 (100.0)
Regular physical activity helps to control hypertension.Yes16 (72.7)22 (100.0)
Low-sodium diet is important for controlling hypertension.Yes15 (68.2)22 (100.0)
Weight reduction helps to control hypertension.Yes10 (45.5)20 (90.9)
Once hypertension is controlled, drugs can be stopped.Yes4 (18.2)21 (95.5)
Hypertension is associated with the overconsumption of alcohol and smoking.Yes13 (59.1)20 (90.9)

Changes in hypertension self-management

The paired sample Student's t-test was used to compare the hypertension management levels before and after the CBCM program. Table 3 shows the changes in the mean score before and after the CBCM program.

Table 3. Changes in mean score in hypertension self-management before and after CBCM (n = 22)
 Mean (SD)tp
Before CBCMAfter CBCM
  1. Comparisons were done by paired sample Student's t-test. P < 0.05. CBCM, community-based case management; SD, standard deviation.

Lifestyle10.64 (2.65)12.86 (1.49)−4.839<0.001
Physical activity3.32 (0.89)5.18 (0.96)−6.622<0.001
Diet10.00 (1.90)14.81 (2.02)−6.931<0.001
Medication3.14 (1.49)5.09 (0.97)−5.667<0.001

There were significant changes in the mean score assigned by patients for hypertension management in the categories of lifestyle (t = −4.839, P < 0.001), physical activity (t = −6.622, P < 0.001), diet (t = −6.931, P < 0.000), and medication (t = −5.667, P < 0.001).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Measures
  6. Results
  7. Discussion
  8. Acknowledgments
  9. Conflict of interest
  10. References

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.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Measures
  6. Results
  7. Discussion
  8. Acknowledgments
  9. Conflict of interest
  10. References

We would like to thank all those who participated in this study, as well as the nurses of Dongjak Healthcare Center, without whom this work would not have been possible.

Conflict of interest

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Measures
  6. Results
  7. Discussion
  8. Acknowledgments
  9. Conflict of interest
  10. References

The authors of this paper have no conflicts of interest to report. All authors have materially participated in the research and/or article preparation. All authors have approved the final article.

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  2. Abstract
  3. Introduction
  4. Methods
  5. Measures
  6. Results
  7. Discussion
  8. Acknowledgments
  9. Conflict of interest
  10. References
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