Nurse-led community care
9.1. Introduction
In this chapter we examine the clinical and cost effectiveness of nurse-led community care and whether extended access to these services is appropriate.
“Community nursing encompasses a diverse range of nurses and support workers who work in the community including district nurses, intermediate care nurses, community matrons and hospital at home nurses”.105 Within this chapter community matrons and community specialist nurses will be referred to as well as community/district nurses.
This chapter firstly evaluates the clinical and cost effectiveness of nurse-led community care including evidence of community matrons as well as community specialist nurses.
A community matron has been described as a “highly experienced senior nurse who works closely with patients (mainly those with serious long term conditions or complex range of conditions) in a community setting to directly provide, plan and organise their care.107 Community Matrons were introduced in 2004 in response to a growing awareness that “Care of patients with multiple long-term conditions has been uncoordinated historically, ad hoc, reactive care with little preventive intervention in the absence of one specific healthcare professional responsible for overall health and social care needs”.41
A community specialist nurse is a senior nurse with specific knowledge and experience in one condition often Heart Failure, COPD, Multiple Sclerosis, Parkinson’s disease, Diabetes. They may be based in and employed by acute or community trusts and will provide support to GP’s and the district nursing teams in the management of symptoms and exacerbations. Specialist nurses will hold individual caseloads and often visit patients in hospital or at home and write admission avoidance plans with patients. They will often have strong links with the teams in the acute sector.
The increasing incidence of people living with multiple long-term conditions and increasing care costs resulted in government legislation.39,40,42,43 The National Service Framework for Long-Term Conditions43 provided a framework that advocated person-centred care in a service that is efficient, supportive and appropriate at every stage from diagnosis to end of life”.99
In this chapter we also examined whether extended access to community nursing/district nursing is more clinically and cost effective than standard access. This focuses on extending and standardising the current provision of the existing services, specifically district nurse teams in light of the move towards a comprehensive 7 day service across the NHS.
The current challenges facing the NHS are well known, and community nursing in all forms could be part of the solution for achieving the goals set out in the Five year forward View: enabling people with increasingly complex levels of health and social care requirements to be able to receive care close to home, have timely and appropriate discharge from hospital and have reduced need for unplanned care.
9.2. Review question: Does community matron or nurse-led care improve outcomes compared to usual care?
For full details see review protocol in Appendix A.
Table 1
PICO characteristics of review question.
9.3. Clinical evidence
We searched for systematic reviews and randomised trials comparing the effectiveness of community matron/nurse-led interventions with usual care to improve outcomes for patients.
We identified 2 Cochrane reviews evaluating nurse-led interventions compared to usual care.133,142 The reviews were assessed for relevance to the review protocol and methodology and were adapted and updated as part of this systematic review. Data for the studies presented in the Cochrane reviews has been included in the analysis. We have updated the Cochrane reviews with additional randomised controlled trials found from the search.
The Cochrane review133 included RCTs comparing disease management interventions specifically directed at patients with chronic heart failure (CHF) to usual care. The review had 3 interventions: 1) case-management interventions, where patients were intensively monitored by telephone calls and home visits, usually by a specialist nurse; 2) clinic interventions involving follow up in a specialist CHF clinic; 3) multidisciplinary interventions (a holistic approach bridging the gap between hospital admission and discharge home delivered by a team). Only the case-management intervention by a specialist nurse matched our protocol criteria and studies from the other two interventions were excluded. The Cochrane review143 included RCTs evaluating respiratory health care worker programmes for COPD patients. Only those studies from the Cochrane reviews meeting our protocol criteria were included in our evidence review. The Cochrane reviews included only CHF and COPD patients so additional RCTs were included in other populations. Also, RCTs published after the Cochrane reviews were included.
Fifty three studies were included in the review (2 of which were Cochrane reviews); these are summarised in Table 2 below. Evidence from these studies is summarised in the clinical evidence summary below (Table 3). See also the study selection flow chart in Appendix B, study evidence tables in Appendix D, forest plots in Appendix C, GRADE tables in Appendix F and excluded studies list in Appendix G.
Table 2
Summary of studies included in the review.
Table 3
Clinical evidence profile: Matron/nurse-led care versus usual care.
Narrative findings
Length of stay
Allen 20096 reported the average hospital days for the intervention group (post discharge care management) and control group (stroke unit care only). The study reported a decrease in average hospital days for the control group (post discharge care management: 1.6 days; stroke unit care only: 1.4 days). This study also reported a value for difference in intervention minus control and difference in SD units, 0.2 (0.04).
Latour 200686 reported duration (length of stay) of all emergency readmissions as 11 days (range: 4-59) for the control group and 10.5 (range: 2-68) days for the case management intervention group, but this difference was not statistically significant (95% CI: −13 to 6.0 days).
Martin 199493 reported a median of 0 inpatient days (range 0-14) and 25 inpatient days (range 0-75) for the home treatment group and the control group respectively at 12 weeks follow-up.
In Jaarsma 200870 the median duration of admissions to the hospital because of heart failure in both intervention arms (basic support group: 8.0 days, IQR 4.0-14.0; intensive support group: 9.5 days, IQR 5.0-17.0) was shorter compared with the control group (12.0 days, IQR 5.0-19.5; basic support group versus control, p=0.01; and intensive support versus control, p=0.29).
Quality of life (Minnesota Living with Heart Failure scale)
Allen 20096 reported the average quality of life score for the intervention group (post discharge care management) and control group (stroke unit care only). Stroke Specific-QOL was used as the quality of life measure, the measure has a sum of 49 items with a score range from 49-245; a higher score is better. The study reported a better average quality of life score for the control group (post discharge care management: 196; stroke unit care only: 199). This study also reported a value for difference in intervention minus control and difference in SD units, −2 (−0.07).
Using the Minnesota scale, Doughty 200244 found that the scores at baseline showed markedly impaired quality of life; mean baseline functioning score was 25.6 (SD 12.4) and emotional score 10.0 (SD 7.8). There was a significant improvement in physical functioning from baseline to 12 months between the intervention and control groups (−11.1 and −5.8 respectively, p=0.015). There was no significant change in the emotional score between the 2 groups from baseline to 12 months (−3.3 and −3.3 respectively, p=0.97).
Kasper 200277 found that overall quality of life improved for both groups, but patients in the nurse-led intervention group improved more (change from baseline: mean= −28.3, median −28.0) than the usual care group (change from baseline: mean= −15.7, median −15.0; p=0.001).
9.4. Economic evidence
Published literature
Three economic evaluations were identified with the relevant comparison and have been included in this review.55,112,136 These are summarised in the economic evidence profile below (Table 4) and detailed in the economic evidence tables in Appendix E.
Table 4
Economic evidence profile: Community nurse-led care.
Four economic evaluations relating to this review question were identified but were excluded due to a combination of limited applicability and methodological limitations, and the availability of more applicable evidence.50,51,57,85 These are listed in Appendix H, with reasons for exclusion given.
The economic article selection protocol and flow chart for the whole guideline can found in the guideline’s Appendix 41A and Appendix 41B.
9.5. Evidence statements
Clinical
- Seventy-one studies evaluated the role of nurse-led care for improving outcomes compared to usual care provided in the community in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that community matron or nurse-led care may provide a benefit in reduced mortality (34 studies, moderate quality), improved quality of life (5 different scores, very low to moderate quality), reduced length of stay (12 studies, moderate quality), improved patient and/or carer satisfaction in studies in which a high score indicated a higher satisfaction (2 studies, high quality) and reduced re-admission (2 studies, low quality). However, the evidence suggested there was no effect for patient and/or carer satisfaction in studies when a low score indicated higher satisfaction (1 study, low quality) and when employing a dissatisfaction score (1 study, very low quality). Dichotomous data suggested a benefit for admission (28 studies, low quality), GP visits (5 studies, very low quality) and ED admissions (8 studies, very low quality) whereas continuous data suggested no difference for admission (6 studies, high quality), GP visits (2 studies, moderate quality) and ED admissions (4 studies, moderate quality).
Economic
- Two cost-utility analyses found that for adults at risk of an AME, community nurse-led care was dominant (less costly and more effective) compared to usual care in the community. Both studies were assessed as partially applicable with minor limitations.
- One cost-utility analysis found that for adults at risk of an AME, community nurse-led care was cost-effective (ICER: £14,900 per QALY gained) compared to usual care in the community. This study was assessed as directly applicable with minor limitations.
9.6. Recommendations and link to evidence
Extended access to community nursing
9.7. Review question: Is extended access to community nursing/district nursing more clinically and cost effective than standard access?
For full details see review protocol in Appendix A.
Table 5
PICO characteristics of review question.
9.8. Clinical evidence
No relevant clinical studies were identified.
9.9. Economic evidence
Published literature
No relevant economic evaluations were identified.
The economic article selection protocol and flow chart for the whole guideline can found in the guideline’s Appendix 41A and Appendix 41B.
9.10. Evidence statements
Clinical
No clinical evidence was identified.
Economic
No relevant economic evaluations were identified.
9.11. Recommendations and link to evidence
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Appendices
Appendix A. Review protocols
Table 6
Review protocol: Matron/nurse-led care versus usual care from EVIBASE.
Table 7
Review protocol: Is enhanced community nursing/district nursing more clinically and cost effective than standard access?
Appendix B. Clinical study selection
Figure 1Flow chart of clinical article selection for the review of community matron/nurse-led interventions
Appendix C. Forest plots
C.1. Matron or nurse led care
C.1.1. Matron or nurse-led interventions versus usual care
Figure 13Matron/nurse led care versus usual care: Emergency department admissions (dichotomous data)
C.2. Extended access to community nursing
No relevant clinical evidence was retrieved.
Appendix D. Clinical evidence tables
D.1. Matron or nurse-led care
Cochrane reviews
Download PDF (829K)
Individual studies (not reported in Cochrane reviews)
Download PDF (1.1M)
D.2. Extended access to community nursing
No relevant clinical evidence was retrieved.
Appendix E. Health economic evidence tables
E.1. Matron or nurse-led care
Download PDF (543K)
E.2. Extended access to community services
No economic studies were included.
Appendix F. GRADE tables
F.1. Matron or nurse-led care
Table 8
Clinical evidence profile: Matron/nurse-led care versus usual care.
F.2. Extended access to community nursing
No GRADE tables were included.
Appendix G. Excluded clinical studies
Table 9
Studies excluded from the matron or nurse-led care clinical review.
Table 10
Studies excluded from the extended access to community nursing clinical review.
Appendix H. Excluded health economic studies
Table 11
Studies excluded from the matron or nurse-led care economic review.
No economic studies were excluded in the extended access to community nursing review.
Publication Details
Copyright
Publisher
National Institute for Health and Care Excellence (NICE), London
NLM Citation
National Guideline Centre (UK). Emergency and acute medical care in over 16s: service delivery and organisation. London: National Institute for Health and Care Excellence (NICE); 2018 Mar. (NICE Guideline, No. 94.) Chapter 9, Community nursing.