Table 5.
Frequency of nurse care manager activities in notes and by unique number of participants
| Nurse Care Management Activities | Notes | Participants |
|---|---|---|
| (n = 656) | (n = 140) | |
| n (%) | n (%) | |
| Nursing Assessment | ||
| Administered initial or re-assessment | 169 (25.8) a | 140 (100.0) |
| Reviewed transitional care after a hospitalization | 11 (1.6) | 9 (6.4) |
| Nursing Diagnoses | ||
| Identified/discussed new problem(s) | 267 (39.6) | 112 (80.0) |
| Algorithm-identified problems in initial or reassessment | 169 (25.8) | 140 (100.0) |
| Planning Outcomes (Goal Setting) | ||
| Motivational collaborative problem-solving | 144 (21.4) | 71 (50.7) |
| Implementing Interventions (Coaching) | ||
| Provided counseling + emotional support | 387 (57.4) | 121 (86.4) |
| Discussed medication management | 349 (51.8) | 124 (88.6) |
| Provided education – verbal | 310 (46.0) | 107 (76.4) |
| Initiation of care coordination | 289 (42.9) | 95 (67.9) |
| Discussed/made referrals | 279 (41.4) | 98 (70.0) |
| Discussed Siebens Health Care Notebook | 222 (32.9) | 108 (77.1) |
| Encouraged/assisted in making appointments | 173 (25.7) | 79 (56.4) |
| Provided education – written materials to be mailed | 168 (24.9) | 102 (72.9) |
| Facilitation of social support | 140 (20.8) | 63 (45.0) |
| Recommended topic/intervention to discuss with a provider | 129 (19.1) | 61 (43.6) |
| Encouraged follow-through with a provider | 103 (15.3) | 51 (36.4) |
| Recommended a specific care intervention to participant | 74 (11.0) | 45 (32.1) |
| Provided education online or electronic (DVD) resources | 68 (10.1) | 38 (27.1) |
| Discussed Davis Phinney Binder | 30 (4.5) | 18 (12.9) |
| Discussed My Action Plan | 13 (1.9) | 11 (7.9) |
| Recommended voice exercises | 8 (1.2) | 5 (3.6) |
| Discussed stress management | 7 (1.0) | 7 (5.0) |
| Evaluating | ||
| Followed-up to monitor progress/ follow-up on prior problems | 375 (55.6) | 113 (80.7) |
| Followed-up involving care coordination/prior referrals | 93 (13.8) | 39 (27.9) |
| Formal discussion of initial assessment | 16 (2.4) | 15 (10.7) |
| Formal discussion of reassessment | 1 (0.1) | 1 (0.7) |
| Other | 18 (2.7) | 15 (10.7) |
| Documented future nurse care manager plans | 465 (69.0) | 119 (85.0) |
a This represents the 140 initial assessments and the 29 reassessments
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