There is a projected explosion of patients with chronic illnesses in the U.S. The Federal Government is developing Chronic Care Improvement Program (CCIP) models through the Medicare Modernization Act. CCIP is a series of demonstration projects focused on helping those with chronic illness improve their health status and, implicitly, reduce Medicare expenditures. One major focus is promoting self-care strategies for these patients.
Home care nurses have a head start in caring for these patients as the majority of care we provide is for people with multiple chronic illnesses. Yet there is one essential component on caring for the chronically ill that nurses need to focus their attention-self-care. While we are experts at patient education, there appears to be less focus on encouraging patients to better care for themselves.
Examples of Self-Care
For patients with symptomatic chronic illnesses, symptom diaries can be effective in promoting self-care. For example, in patients with COPD, symptoms of breathlessness do not necessarily correspond with changes in pulmonary function, and yet it is the symptoms that drive patients to seek care. Using a simple set of symptom diaries for breathlessness, cough, and sputum production in a chart or graph allows the nurse to examine trends and then assist the patient in doing the same. When symptoms occur, nurses can help patients decide appropriate action and who to call for advice and intervention.
A second example is telehealth interventions designed to promote self-care (e.g., Health Hero's HealthBuddy). Designed to assist patients with heart failure and other chronic conditions, these systems provide a daily contact with a healthcare professional to monitor the patient's weight, edema, and breathlessness. Evidence continues to build on the effectiveness, both in cost and averting the use of more expensive services, of these telehealth supports.
The important argument to the contrary is that there is still no reimbursement for these systems. Assuming that federal policy is developed rationally and follows directly from research evidence is naive at best. Yet, there are other examples of how reimbursement changes followed public demand for services (e.g., dialysis care in the 1960s). Because the Medicare program is driving the initiative, a better possibility of reimbursement for this kind of care exists.
Learning About Self-Care Emphasis from Nurses Worldwide
In countries where there are fewer nurses per person, the outcomes of using self-care care models have been notable. In Chile, the Catholic University of Chile, with funding from the W. K. Kellogg Foundation, developed a patient self-care guide series to promote self-care among patients with common conditions. While nurses in these shortage areas would support more nurses to provide comprehensive care, the scarcity of nurses drives the focus on how they can help patients help themselves. Similar approaches have not been as wide spread in the U.S.
The self-care philosophy is consistent with the philosophy of home care nursing practice-assisting patients to regain, maintain, or attain the best health state possible. Creative self-care strategies best comes from clinicians involved in practice. Do you have ideas or suggestions on ways to improve self care in your patients? What has worked or not worked? Are there specific patient groups for whom self-care has been particularly effective?
Send these ideas to me; the best will be published in a future Commentary. We have a long history of caring for the chronic ill-our voices are important as chronic illness care becomes a national priority.