Integrated Management of Chronically ill Patients: Nurse-client interactions and follow-up care

Follow-up care ensurescontinuity of client care, gives room for provider-client interactions and sustains self-management measures in the client with chronic illness. This study examined nurse-client interactions and follow-up care in integrated management of the chronically ill patient. 240 nurses were selected from secondary and tertiary health institutions in Anambra State of Nigeria using purposive sampling technique. Two research questions and two null hypotheses guided the study. The instrument used for data collection was questionnaire on nursing interventions in integrated management of chronically ill patients. Standard descriptive statistics was used to summarize the variables. Mean scores were used to answer the research questions while chi-square test was adopted in testing the hypotheses at 0.01 level of significance. The result indicated high level of nurse-client interaction (mean = 3.1368) but average level of follow-up care (mean =2.1556) of clients by nurses. Client's medical diagnosis was observed to have significant influence on nurse – client interaction; also nurse-client interactions was found to differ significantly across the levels of health care institutions.


INTRODUCTION
A chronic illness is one that lasts for an extended period, usually six months or longer, and often throughout the persons life (Kozier, Erb, Berman and Snyder, 2004). Chronic illnesses usually have slow onset and periods of remission when the symptoms disappear, and exacerbation when the symptoms reappear (Kozier et al. 2004). WHO (2002) defined Chronic conditions as requiring ongoing management over a period of years or decades.Chronic conditions cover a wide range of health problems such as heart disease, diabetes, lung disease eg asthma, HIV/AIDS, mental disorders (such as Depression and Schizophrenia), disabilities and impairments such as musculoskeletal disorders and cancer (WHO, 2002;Coleman etal 2008). Studies have revealed that chronic conditions frequently go untreated or are poorly controlled until more serious and acute complications arise (McGlynn etal. 2003). Advances in healthcare that keep people alive while controlling, although not curing their conditions have led to growing numbers of people surviving with chronic illnesses (TNS Opinion and Social, 2007). The Common theme is that people with chronic illness require a complex response over an extended time period that involves co-ordinated inputs from a wide range of health professionals, and access to essential medicines and monitoring systems, all of which need to be optimally embedded within a system that promotes patient empowerment (Conrad and Shortell, 1996;Unwin etal. 2004; . According to Plochg and Klazinga (2002), the increasing prevalence of chronic illness is posing considerable challenges to health systems. Patients may receive care from many different providers, often in different settings or institutions, even when they have only a single disease such as diabetes. They are frequently called upon to monitor, coordinate or carryout their own treatment plan while receiving limited guidance on how to do so. Plochg and Klazinga (2002) pointed out that there is pressing need to bridge the boundaries between professionals, providers and institutions through development of more integrated or coordinated approaches to service delivery so as to provide better support for the patients. Integrated care connotes a range of approaches that are deployed to increase coordination, cooperation, continuity, collaboration and networking across the different components of health care delivery (Simeons and Scott, 1999) involving patient and family (Blackie, 1998 engage in activities that promote physical and psychological well-being to interact with healthcare providers and adher to treatment regimen, monitor their health status and make associated care decisions, and to manage the impact of the illness on physical, psychological and social functioning (Clark, 2003). Bayliss et al. (2003) noted that the increasing responsibility taken by patients for self management can create particular challenges for those with multiple conditions as they may experience aggravation of one condition by treatment of another, for example, a patient with chronic respiratory disease may struggle to adhere to exercise programmes designed for his/her diabetes. Grumbach (2003) observed that the goals of chronic care are not to cure but to enhance functional status, minimize distressing symptoms, prolong life through secondary prevention, and enhance quality of life. According to , it is clear that these goals are unlikely to be accomplished by means of traditional approach to health care that focuses on individual diseases and based on a relationship between an individual patient and a physician; but it is clear that what is needed is a model of care that takes a patient-centred approach by working in partnership with the patient and other healthcare personnel to optimize health outcomes. Crumbie (2005) stated that the advantage of integrated team work is that the patient is treated more holistically and is more likely to be able to see the value of the services provided. Wagner et al. (2001) developed the influential chronic care model (CCM) aimed to provide a comprehensive framework for the organization of healthcare to improve outcomes for people with chronic conditions, which was based on the premise that high-quality chronic care is characterized by productive interactions between the practice team and patient, involving assessment, selfmanagement support and optimization of their therapy and follow-up. Eventhough not exhaustive, inclusive in these health professionals that make up the practice team are physicians, nurses, pharmacists, physiotherapists, radiographers, laboratory scientists, record officers, social workers, psychologists, and ancillary staff.  opined that effective responses will require initiatives at all levels to ensure that the right resources can be assembled in the right place at the right time while establishing support and initiatives for everyone to work together to achieve this shared aim.  further added that there is also considerable scope for shared learning from each others successes and failures. It is against this background that this study examined nurse-client interactions and follow-up care in integrated care of chronically ill patients.

Research Questions
 To what extent do nursesinteract with their patients/clients while discharging their integrated care of the chronically ill patients?  What is the extent of nurses follow-up care of their clients inintegrated management of chronically ill patients? Hypotheses  Patient's medical diagnosis does not significantly influence nurse-patient interactions in integrated management of chronically ill patients.
 Nurse-patient interactions in integrated management of chronically ill patients do not significantly differ between secondary and tertiary health care institutions.

II. MATERIALS ANDMETHODS. Design and Sampling.
The study was a cross-sectional research design. Purposive sample of 240 nurses working in two levels of Health care institutions (five General Hospitals and two Teaching Hospitals) in Anambra State of Nigeria were used for the study. Ethical approval was obtained for the study, and informed consent was obtained from the respondents. Inclusion criteria for the study were all registered nurses with different areas of specialty attending to chronically ill patients in any of the selected health institutions. Exclusion criteria were nurses who have never attended to chronically ill patients and those who indicated not to participate in the study.

Instrument.
Questionnaire on Nursing Interventions in Integrated Management of Chronically ill Patients (QNIIMCIP) was used to obtain data from the respondents. QNIIMCIP was developed by the researchers based on the framework on chronic care model by Wagner et al. (2001). Section A of the instrument elicited information on the demographic characteristics of the respondents (eg.. professional qualifications, sex, years of working experience, setting/unit, and collaboration team). Section B of the questionnaire elicited information on patient-reported demographics and chronic conditions (eg. Age, sex, medical diagnoses, duration of illness, self-management measures, etc), while section C of the instrument elicited information on nursing interventions in integrated care of chronically ill patients (eg interactions between the nurses and patients, health assessment of the patients, selfmanagement supports, interactions with the practice team, etc). The responses to section C of the instrument were scored on a 4-point scale ranging from 1 point for less/rarely often, 2 points for fairly often, 3 points for moderately often, and 4 points for very often. The instrument (QNIIMCIP) was tested for reliability. 20 nurses working in a health institution in another zone of Nigeria were used. Internal consistency reliability coefficient was calculated using Cronbach alpha for the entire scales, and a reliability coefficient of 0.70 was obtained.

Data Analysis
Standard descriptive statistics of means, frequency and standards deviation were used to summarize the variables. Mean score and standard deviation were used to answer the research questions. Chi-square test was used to test the null hypotheses at 0.01 level of significance. SPSS version 21 was used in the data analysis.  Table 1 shows the descriptive statistics of the measured variables. Out of the 240 chronically ill patients, the least age was 3 years, maximum age 84 years, mean age 47.4 with standard deviation (SD) of 16.06701. The mean for interaction between nurses and patients was 3.1368 with SD 0.56260; for health assessment of the patients, the mean was 3.0250 with SD of 0.61769. Self-management support had a mean of 3.1017 with SD of 0.57056; optimization of client therapy had a mean of 2.9806 with SD of 0.51649. For interaction between the practice team, the mean was 2.7212 with SD of 0.59982. Follow-up care of patients had mean of 2.1556 with SD of 0.68311, while evaluating programme of care/nursing audit had mean of 2.9033 with SD of 0.84941. Total number of each variable was 240.

International Journal of Advanced Engineering Research and Science (IJAERS)
[ Vol-5, Issue-3, Mar-2018]  https://dx.doi.org/10.22161/ijaers.5.3.25  ISSN: 2349-6495(P) | 2456-1908(O) www.ijaers.com Page | 204   Table 5 shows that the mean score for extent of the follow-up of the chronically ill clients by nurses was 2.1556 with SD of 0.68311.   Table 7 shows that at 0.01 level of significance, the X 2 of 11.770 was more than the p-value of 0.001. The null hypothesis is therefore rejected. Interactions between nurses and chronically ill patients significantly differ between secondary and tertiary health institutions.

International Journal of Advanced Engineering Research and Science (IJAERS)
[  Wagner et al (2001), patients must have the information, skills and confidence to make best use of their involvement with their practice team. On the other hand, practice teams must have the necessary expertise, relevant patient information, time and resources to act so as to ensure effective clinical and behavioural management. Crumbie (2005) stated that the ability to communicate effectively and to be able to listen to the patient's concerns can have a huge impact upon the patient and his or her family.  stated that high quality chronic care is characterized by productive interactions between practice team and patients. Also DeLaune and Ladner (2002) added that the time frame within which interaction occurs influences the outcomes. The mean of 2.1556 (table 5) for the extent of follow-up care of the clients by nurses,eventhough fair, needs to be intensified. Donabedian and Rosenfeld(1964) observed that something is known about how patients are cared for in hospitals but much less about how they fare when they are discharged. Several follow-up studies have demonstrated the high frequency with which chronically ill patients fail to abide by medical recommendations; lack of compliance had also been found to be associated with recommended modifications in diet, exercise, habits, activities, intake of prescribed drugs, etc (Donabedian and Rosenfeld, 1964). High quality chronic illness care is characterized by productive interactions between practice team and patients that consistently provide the assessments, support for self-management, optimization of therapy and follow-up associated with good outcomes (Wagner et al, 2001). Follow-up care of chronically ill patients can be in form of out-patient clinic visits by the client, home care/visits by the nurse, telephone calls, office visits, etc (Donabedian and Resenfeld, 1964). These services have their general and specific benefits. Follow-up care is not confined to face-to-face visits. Wagner et al (2001) observed that the use of telephone, for example, allows for more intensive cost-efficient follow-up of chronically ill patients. Kamalam (2005) stated that follow-up services are done in some problems identified in Health Centre, Schools and hospitals. The implications of these findings are that follow-up care of the chronically ill patient ensures continuity of care, reduces relapse in the client's condition, reduces rate of hospital redmissions of the client, promotes the client's self-management ability and also increases the client's self esteem. Findings from the study indicate that the medical diagnosis of chronically ill patient significantly influence the interaction between nurses and the client (X 2 = 25.826; p-value=0.007) (table 6). DeLaune and Ladner (2002) stated that therapeutic interaction involves discussing the client's problems, needs or concerns. This implies that client's problem obviously arise from client's medical diagnosis. Clark (2003) noted that chronic illness confronts patients with a spectrum of needs that require them to interact with healthcare providers and adhere to treatment regimens. Lorig and Holman (2003) reported that most interventions address medical or behavioural management tasks; and that this depends on the disease process involved, for example, support programmes for patients with cancer are more likely to address the emotional aspect of the disease than programmes for patients with asthma where correct use of medication comes first. Findings from the study indicate that nurse-client interactions in integrated management of the chronically ill patients differ significantly between secondary and tertiary health institutions (X 2 = 11.770; p-value =0.001) (table 7). DeLaune and Ladner (2002) stated that the complexity of health care services varies according to the delivery setting. Kozier et al (2004) pointed out that the services provided by the health care system is commonly categorized according to type and level.

V. CONCLUSIONS
This study revealed high level of nurse-client interactions and average level of follow-up care by nurses in integrated management of chronically ill patients. Also client's medical diagnosis was observed to have significant influence on nurse-client interactions.In addition, nurse-client interaction was noted to differ significantly between secondary and tertiary health institutions.