Chronic Disease Management for Elderly


Nowadays, the issue of chronic diseases is very common among elderly people. In 2012, more than 117 million people had at least one of the chronic disease conditions in the United States (US) with the low-income population being the most affected population (Centers for Disease Control and Prevention [CDC], 2015). These diseases pose a tremendous challenge to the low-income elderly population who must seek care in places that offer inexpensive medical services. Health care costs associated with the care of diabetes, heart diseases, and stroke were more than $560 billion in 2012, a figure that is likely to grow, following the ever-rising aging population and chronic disease burden (CDC, 2015). Nurses should design models of care that can help to achieve better low-income older patient outcomes and simultaneously minimize the care costs for the benefit of the elderly. The Elder Nursing Home Hospital Model (ENHHM) enhances care delivery to low-income older people.

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Elder Nursing Home-Hospital Model

The current model will apply to nursing homes for elderly patients who suffer from chronic diseases. The primary aim of the ENHHM is to enhance the provision of quality health care services while minimizing healthcare costs. Nurses will be the primary providers of health services in nursing homes to the full extent of their knowledge and expertise. This will be in agreement with the Institute of Medicine’s (2011) report, which asserts that nurses should practice to the full extent of their education and training. However, nurses will be seeking for assistance from specialists and physicians in case of consultations or specialist care.

The model discourages the elderly patients from going to regular hospitals to receive specialist care, unless the situation is critical. Such an approach is fundamental in reducing the care costs patients with chronic diseases can incur because of movements and unnecessary hospital visits. Computer technologists will work on designing a program that will help in processing, storing and retrieving patient information in the nursing homes. Therefore, all patient records will be performed in electronic form. Most importantly, the information will be accessed from the patient’s hospital facility, from which care specialists situated at the facility can review the records and communicate with nurses at the nursing homes. It is through these platforms that consultations will be made between nurses residing with older patients and specialists working in hospital facilities. Communication will further be aided through mobile phone calling and video calling. Experts can also use this platform to communicate directly with the patients. Specialists will be visiting patients in nursing homes only when the need arises, but the patients will only visit the hospital in critical cases, whereby care requires the use of equipment or resources that are not found in nursing homes.

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Partnerships and Collaborations

The ENHHM will be managed and implemented by nurse practitioners in close collaboration with case managers who will partner with other healthcare professionals. According to Fitzpatrick (2010), nurse practitioners should work in a partnership with case managers and other staff in holistically assessing patients, addressing the upcoming barriers, and providing quality care services. Furthermore, nurses should take the leadership roles in planning, providing care to the full extent of their training, and formulating health policies (Wilson, Whitaker, & Whitford, 2012; IOM, 2011). However, nurses will consult with physicians and chronic disease specialists who will communicate through computers, using video calls, or with the help of their mobile phones. Nursing homes will also have physicians who will either be working part-time or full-time. Nutritionists will provide nutritional services, while pharmacists will dispense medications.

Continuity of Care across Settings

The use of electronic health records that can be accessed between hospital facilities and nursing homes will enhance the continuity of care between the two settings. In case a patient is taken to the hospital for admission, the health records used in nursing homes will be utilized in determining the care. Nursing homes will equally have access to the information received from hospitals because the two facilities will be using the same patient records. Therefore, the electronic sharing of information on patient care will enhance continuity of care.

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Technology Use

The use of technology is the backbone of this model. Communication between nurses and other health care providers, as well as patients, will be realized through the use of computer technology and mobile phones. Knowledge and skills in health informatics play an essential role in enhancing successful inpatient care(Lavin, Harper, & Barr, 2015). Furthermore, the use of health informatics by nurses and other care professionals, increases the ease of communication, sharing, storage, and retrieval of patient information Lavin, Harper, & Barr, 2015). This platform is cheap because the movement to convey information and cumbersome paperwork is eliminated. This technology positively impacts low-income elderly patients with chronic conditions because they pay less for quality services.


Various aspects of the model outcome will be evaluated. For example, patient satisfaction and the number of hospital-nursing home movements by the patients will be assessed. This model aims to increase the patients’ satisfaction with care services and a reduction in movements of patients between nursing homes and hospitals. Most importantly, patient outcomes of chronic disease management and care costs will be at the helm of ENHHM evaluation.


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The ENHHM will help the older low-income people who suffer from chronic conditions spend less on health care services while being in nursing homes. The costs of hospitalizations and frequent hospital visits are a burden to these patients. This model provides for the use of technology in enhancing the communication between nursing homes and hospitals. Nurses are the managers who will implement the model, but they need the help of other professionals. Experts and physicians will be accessed with the help of technology devices. Electronic health records will be shared, which is something that will enhance continuity of care. The model will be evaluated by the number of patient movements between hospitals and nursing homes, patient satisfaction, care costs, and improvement in patients’ outcomes.

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