Community-based nursing clinics have historically recognized the relationship between the principles of community health nursing and the practice of primary health care, however few models exist that operationalize and evaluate the effectiveness of these concepts in practice. Open Gates Health Center, a nurse-managed clinic operated by the University of Maryland School of Nursing, has implemented an innovative approach to community-based primary care that utilizes community health outreach workers as extenders of the nurse-managed team for disease management of underserved patients in a poor urban community.
Community health outreach workers have been trained by University of Maryland School of Nursing faculty to provide home visitation and community outreach to patients treated at the Open Gates Health Center. The four targeted clinical areas of child health, pre-natal care, uncontrolled hypertension and uncontrolled diabetes that have been selected as the focus for the community health outreach worker disease management intervention will be described. The components of the critical pathways developed for implementation by lay health workers in the home setting will be discussed. Clinical outcomes include changes in health status, compliance with treatment plans, attendance at primary care visits, knowledge of specific health care information, and patient satisfaction. Financial outcomes include utilization of emergency room services, utilization of acute care hospital services, utilization of specialty care services and overall cost of care. Preliminary data and discussion of the model and its application to primary care and community health planning will be presented.
Learning Objectives: At the conclusion of this session, the participant will be able to: 1. Identify and critically analyze the unique role community health workers can play as adjunct to primary care services delivered in a nurse-managed clinic. 2. Describe the use of community health outreach workers in community-based disease management and the their application to managed care and cost containment. 3. Identify the clinical and health care utilization outcomes of the community health outreach worker approach to disease management in a nurse-managed model. 4. Discuss the critical components of a community health outreach worker disease management program and lessons learned from implementation of the University of Maryland School of Nursing's Open Gates model
Keywords: Disease Management, Community-Based Health Care
Presenting author's disclosure statement:
Organization/institution whose products or services will be discussed: None
I have a significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.
Relationship: Employed by University of Maryland School of Nursing as Assistant Dean for Clinical Practice and Service, the department directly responsible for this program. Co-Principal Investigator on grant funding development of this program.