Dianne Liebel, PhD, MSED, RN

Bio

During Dr. Liebel's 15-year research career at the SON she has worked conscientiously to conduct a program of research focused on the use of innovative nurse models of care management designed to improve the quality of life and health outcomes of older persons experiencing multiple chronic conditions (MCC), depression, and disability. This research is a natural outgrowth of Liebel’s initial work as a project manager for the "Medicare Primary and Consumer-Directed Care Medicare Demonstration" (MCPC), an RCT trial conducted across 3 states, providing comprehensive care management to community-dwelling older Medicare beneficiaries (n=1600)who had an existing disability and prior use of healthcare (e.g. hospitalizations).  Liebel was a member of the core research team, responsible for the implementation and management of all phases of the research project including the implementation of nurses' intervention arm (e.g., health promotion, disease management, coaching/empowerment, goal setting/behavioral change) as well as joint visits with nurses, PCP,s, and patients. Outcome evaluation of the Medicare Demonstration showed favorable health outcomes among participants (e.g., less disability worsening) as well as a reduction in healthcare cost and use (le.g., less NH use). Notably, this trial was one of only six studies to achieve less disability among these older persons who were experiencing high levels of health complexity. Liebel also conducted and published results from a process evaluation of the nurse intervention, finding good fidelity and participant engagement as well as identifying the select nurse activities instrumental in achieving the beneficial disability outcomes (i.e., disease/medication self-management, goal setting showed ting, family conference visits, and visit dose). During her tenure as a Post-Doc Fellow in Geriatrics and Geronotlooigy (T-32) and faculty roles, she continued to conduct multiple analyses and evaluations of the MCDC trial data (i.e., BMI, individual IADL/ADL, and personal care use). The evaluation results were disseminated in a series of publications and presentations,  providing considerable evidence to support Liebel's research agenda- to promote the use of integrated care management (ICM) nurse interventions in acute Medicare home healthcare settings.  

Simultaneously, Dr. Liebel developed an academic partnership with the SON and the University of Rochester Medical Home Care (URMHC) agency to conduct a series of qualitative and quantitative descriptive research studies with agency nurses exploring the delivery of ICM (e.g., depression care management (DCM); disability care management) during episodes of care. A chart review (N=100) determined that when nurses used depression care plans depression was less, Qualitative analyses of data from nurses' interviews and focus groups showed that agency nurses were not confident in providing ICM or DCM. Thus, Dr. Liebel designed, developed, and tested evidence-based strategies and educational tools/courses for HHC nurses to use based on best practices in DCM as well as her own research findings. Subsequently, after conducting observation visits in the home, she saw the need to develop a therapeutic communication curriculum that nurses could use to more efficiently address health complexity. Liebel also presented and published about how the nurse-patient relationships were the primary mechanism for the effective delivery of ICM leading to improved health outcomes (e.g. delaying or slowing patients’ physical decline) and community-level outcomes. Next, Liebel used the results from the evaluation of the tools to develop a new ICM intervention named NSPIRE (Interactive Nursing Support to Promote Integrated care for elders REceiving HHC). She has applied for funding to NIH and other funding sources to test and evaluate the intervention in a Medicare setting.

In addition, she has continued to augment her education and expertise in population health on a national and international level. For example, she was invited to attend the International Summer Institute on Integrated Care (Oxford, England) and completed an Integrated Care Management certification course (developed by CMSA). Liebel also teaches multiple courses in her faculty role such as Population Health, Program Evaluation, Research, and Population Health and Care Management

Overall, these enhanced skills have enabled her to act as an effective interface between the HHC system, nursing students, older persons, and communities.

Current Focus

I have worked conscientiously to conduct a program of research, improve my teaching practice, and engage in professional activities related to comprehensive care management of aging populations. My program of research explicitly targets improving the quality of life among older persons with multiple chronic conditions (MCC), depression, and disability in the following ways. First, by conducting community-based exploratory research to illuminate the substantial health disparities experienced by this population. Second, by designing, implementing, and evaluating the effectiveness of nurse-led models of integrated care management (ICM) designed to improve disability and depression outcomes for persons receiving home health care (HHC) services. Third, I have established a track record of peer-reviewed (i.e., first and second authored) publications, about this understudied sub-population of vulnerable older persons. Fourth, I provide clinical expertise about principles of population-based approaches to healthcare, including health promotion, community health, integrated care, and evidence-based programs (e.g., health prevention programs;