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DESCRIPTIVE TITLE OF APPLICANT'S PROJECT* INSPIRE HHC: Interactive Nursing Support to Promote Integrated Care for Elders REceiving Home Health Care


Dianne Veronica Liebel ,

University of Rochester, New york, US
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Bethel Powers,

University of Rochester, New york, US
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Julie Salo,

UR Homecare, Rochester, New York, US
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Andrea Middleton

UR Homecare, Rochester, New York, US
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Background: Integrated Care Management (ICM) that delivers patient-centered physical and psychosocial nursing care, produces superior health outcomes (e.g., less disability /depression/hospitalization) in older vulnerable persons who have multimorbid conditions including depression. 1-4 However, physical and psychosocial ICM is rarely found in Medicare home healthcare (HHC) settings, where the bulk of healthcare services are provided to older persons with multimorbidity.  Instead, current HHC services provide care management for HHC patients short-term needs, following an acute illness, injury, or disease exacerbation,5 despite the existence of high levels of disability (40-70%), depression (40-70%) 6-10 and multiple illnesses (80%+). When multimorbidity needs are identified, the emphasis for care is placed on treatment strategies for physical health rather than ICM.9,10 This traditional service approach results in persons receiving segregated physical and mental healthcare as well as a lack of coordination between providers leading to untoward outcomes (e.g. medication errors).20-26  Yet, providing ICM to persons with multi-morbidities receiving HHC requires a uniquely different skill set for nurses.9 Thus, we developed a novel ICM education/training course, for nurses designed to provide them with skills needed to deliver ICM to their older patients to prevent disability worsening and improve psychosocial health.

Design: The study used a mixed method design to develop an evidence-based hybrid online educational program. The program focused on the following 4 content areas and is informed/guided by the Chronic Care Model (CCM), ICM competencies, and expert panel (PNP, DNP, Ph.D.): (1) recognizing, treating, and providing depression care management (2) learning communication skills and developing therapeutic relationships, (3) goal setting and behavior change self-care management (4) facilitating integrated, coordinated, and interprofessional teams’ management.After development/pre-testing the course with supervisory staff, the course was pilot-tested with experienced nurses.

Results: Surveys results from the pre-test by the expert panel demonstrated agreement the course was acceptable to use within the Medicare HHC reimbursement system. The panel provided useful modifications for educational content, skill building, and videos. Nurse post-test scores on module tests and comprehensive exam -showed significant improvement in knowledge and skill building scores and nurses agreed that training was useful and applicable.

Lessons Learned and Suggestions for Future Research: The training curriculum showed improved nurse knowledge and skills needed to address the needs of older persons with multimorbidity and health complexity. We also found that leveraging the on-going nurse-patient relationship occurring during the HHC episode, addressed a missed opportunity to expand and enhance the therapeutic communication skills of HHC nurses’ well within their scope of practice. We will use this course as foundational part of pilot-testing a novel, nurse-supported ICM intervention, for older patients with multimorbid conditions- INSPIRE (Interactive Nursing Support to Promote Integrated care for elders REcieving HHC) designed to prevent disability worsening and improve psychosocial health. The course will be used to train intervention nurses, to ensure they have competencies to assess and provide ICM interventions that address the physical, mental and social health issues of study subjects. Thus, the ICM activities incorporated in this course have the potential to transform the way traditional HHC is practiced.


1- Fabbricotti, I., Janse, B., Looman, W., Kuijper, R., van Wijngaarden, J., & Reiffers, A. Integrated care for frail elderly compared to usual care: A study protocol of a quasi-experiment on the effects on the frail elderly, their caregivers, health professionals and health care costs . BMC Geriatrics, 13, 2013. Available from:

2- Qiu, W., Dean, M., Liu, T., George, L., Gann, M., Cohen, J., & Bruce, M. Physical and mental health of homebound older adults: an overlooked population Journal of the American Geriatric Society, 2010;12(58):2438

3- The nursing role in integrated care models reflecting on the united states’ experience. Royal College of Nursing. Available from:  Https://

4- MacAdam, M. Frameworks of integrated care for the elderly: A systematic review. Ottawa, Canada:Canadian Policy Research Networks. 2008

5- de Bruin, S., Versnel, N., Lemmens, L., Molema, C., Schellevis, F., Nijpels, G., & Baan, C. Comprehensive care programs for patients with multiple chronic conditions: A systematic literature review. Health Policy, 2012;107(2–3):108-145.  Available from: doi:

6- Park, J., Han, M., Kim, M., Yoon, M., Koh, S., Cho, H., & Chung, Y. Predictors of suicidal ideation in older individuals receiving home-care services . Journal of Geriatric Psychiatry, 2014;29(4):367-376.

7- Coventry, P., Lovell, K., Dickens, C., Bower, P., Chew-Graham, C., & Cherrington, A. Integrated primary care for patients with mental and physical multimorbidity: Cluster randomized controlled trial of collaborative care for patients with depression comorbid with diabetes or cardiovascular disease, 2015.

8- Dobson A., DaVanzo, J., El-Gamil, A., Heath, S., Shimer, M., Berger, G., & Freeman, J. Improving health care quality and efficiency (“final report”): Clinically appropriate and cost-effective placement (CACEP) project. 2012 Available from: BMJ, 350, 638. doi:10.1136/bmj.h638

9- Dobson, A., El-Gamil, A., Heath, S., Manolov, N., & DaVanzo, J. Bundling and coordinating postacute care (BACPAC): Toolkit for preliminary modeling and implementation. 2014

10- Dobson, A., El-Gamil, A., Heath, S., Wang, J., Berger, G., & DaVanzo, J. Clinically appropriate and cost-effective placement (CACEP) project working paper series, working paper #2: Baseline statistics of medicare payments by episode type for select MS-DRGs and chronic conditions. 2012.

11- Pickett, Y., Raue, P., & Bruce, M. Late-life depression in homecare. Aging Health, 2012;8(3):273-284. Available from: doi:10.2217/ahe.12.28

12- Liebel, D., Friedman, B., Watson,N. and Powers, B. Review of nurse home visiting interventions for community-dwelling older persons with existing disability. Medical Care Research and Review, 2009;66(2):119-146. PMID: 19114607

How to Cite: Liebel DV, Powers B, Salo J, Middleton A. DESCRIPTIVE TITLE OF APPLICANT'S PROJECT* INSPIRE HHC: Interactive Nursing Support to Promote Integrated Care for Elders REceiving Home Health Care. International Journal of Integrated Care. 2017;17(5):A145. DOI:
Published on 17 Oct 2017.


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