Chronic disease management

Trauma Columnist · Sep 18, 2009

Joe - I do end stage renal disease but like you - these folks should have done something long ago for their DM and HTN.

dansingrn · Sep 18, 2009

I'm an NP in chronic disease management. I work in peds with type 1 diabetes. (The answer is NOT ALWAYS fnp!!)

The time to work on preventing complications is at diagnosis. Therefore, working in peds (as a peds specialist, not the broader fnp) hopefully addresses these very issues.

Proud to be a PNP

Advanced Practice Columnist / Guide · Sep 18, 2009

Joe, your question touched on the very reason why health care needs an overhaul in America. We spend a lot of dollars on hospitalization when patients are seen in the ER with advanced disease instead of nipping the problem in the bud by diagnosing early and making sure patients are followed up. I prefer not to speak of the issue of primary physician shortage attributed to few med school graduates pursuing the field due to low income potential against a backdrop of astronomical med school student loans. However, I will say that the value of NP's (and CNS) are not well appreciated in the field of primary care and illness prevention. I have worked in hospitals most of my entire nursing career and have seen staff cuts including termination of hospital services normally run by an APN where the focus is on health promotion and chronic disease management.

We recently interviewed a long-time NP who happens to also be a CDE who ran an out-patient diabetes program for a large academic center who lost her job to staff cuts. This person is an older nurse who once worked in the ICU in 70's and is now asking to be hired to work in acute care later in her career because she lost her primary care job. I also know of a CNS who ran a heart failure program and was excellent at teaching patients about their cardiac meds, avoiding salt in their diet, weighing themselves daily, etc. to prevent exacerbations and frequent hospitalizations. Guess what? they discontinued her position and she is now a CNS in an ICU. Clearly, the powers that be do not see much benefit in these programs or they do see it but don't see dollar signs with running such programs.

I think you definitely have a novel idea in your head, though not one that has never been tried before. I suggest you investigate the field in the area where you live and maybe you can pursue it if the opportunity is there. Good luck!

JDCitizen · Sep 18, 2009

It is very depressing…………………..

While I kind of a agree that there needs to be an overhaul in health care it’s more than just insurance or the lack of... I have been associated with clinics that could for the most part be compared with the neighborhood health clinics of today; we used sliding scale payments according to financial situation and a lot of free care, a lot of free samples and worked with all the social service organization available. We took care of kids to adults and all too often it was for naught. It’s often more of what the patient is going to put into it than what the provider is going to put into it. Finances are involved but not all the time: Educational variations, social variations, alcohol, drugs, tobacco, indifference or a multitude of other reasons/excuses why people kept coming back into the clinics for the same reason because sometimes it is about laziness…. I have heard too many times; "there is a pill for that". We all do have to get over the idea of going to the doctor to get well… We the people in the good old USofA (federal, state, local, insurance companies and down to me and you) need to start now at looking into ways of getting the point across about chronic illness prevention. Maybe if we can start getting to them all while they still young we can teach all of them and reinforce it day after day, year after year and maybe we can start making a difference. But for right now unfortunately it like the old saying: You can lead a horse to water but you can’t make him drink….

Example of system we have now: A nephrology group I was associated with their dialysis centers were always going full tilt and the dialysis unit in the hospital was also always going full tilt (EXPENSIVE) and that practice was not the only practice in town.

kanzi monkey · Sep 19, 2009

For an NP, what kinds of practice settings/specializations are most conducive to this? I'm not asking about degrees, I know the answer is always "FNP". :chuckle
As opposed to short-term acute care..ie "I have a cold/sprained wrist/poison ivy rash"
Mostly I'm looking to address the twin scourges of HTN and DM2, which seem to be so amazingly prevalent among inpatients.
Usually accompanied by a raft of complications. I've only been an RN for less than a month, yet when I look at this histories of our med-surg patients I get depressed, thinking, "I can't do anything to help this person at this point, something should have been done 10 or 20 years ago."
Thus the interest in chronic disease managment as an NP.

Hi, have you heard of Senior Care Options? Here's a brochure: http://www.mass.gov/Eeohhs2/docs/masshealth/sco/sco_brochure.pdf

It's a relatively new concept, don't know how it works from state to state. The goal is to provide extensive primary care to chronically ill elders (education, med reconciliation/adjustment, referrals, case management, etc) to maximize quality of life and involve the patient as much as possible in care/keep out of hospital or institution. This program focuses heavily on diabetes, hyperlipidemia, htn, obesity, smoking cessation, and COPD. (since these are very common issues, as you have seen)

This may be a great niche for midlevel providers. In MA, it is limited to patients with low-income who qualify for Masshealth (through medicaid). It would be wonderful if these options could be expanded to a wider group of patients. Combine this with some kind of public option health plan, and we're starting to head in the right direction.