Assessing the impact of a community-based nurse-led chronic disease management programme on health system performance: disease control, use of health services and costs

Community Health Posts (CHPs) are neighbourhood-based health touchpoints that bring preventive healthcare services closer to residents. Staffed by community nurses, health coaches, and trained volunteers, CHPs provide health screenings, education, lifestyle advice, and referrals to healthcare or community services. By supporting chronic disease management, CHPs may reduce avoidable healthcare utilisation and costs. However, variability in programme implementation highlights the need for evaluation. This study aimed to assess the effectiveness of CHPs on chronic disease management and healthcare utilisation. This retrospective study analysed electronic health records of residents aged ≥ 18 years with chronic conditions, impaired self-care, or functional decline who were enrolled in the CHP programme between 1 April 2022 and 31 March 2024. Outcomes included chronic disease control, falls, healthcare utilisation, and its associated costs. One-year pre- and post-enrolment outcomes were compared with matched controls using a difference-in-differences approach. Logistic regression, negative binomial regression, and compound Poisson generalised linear models were used for binary, count, and cost outcomes, adjusting for covariates. Improvements in chronic disease control were not significantly different between CHP and control participants for type 2 diabetes mellitus (OR adj = 1.01, 95% CI: 0.72–1.40), hypertension (OR adj = 1.05, 95% CI: 0.84–1.31), or hyperlipidaemia (OR adj = 0.63, 95% CI: 0.35–1.15). CHP participants showed a greater reduction in the proportion with ≥ 1 fall, although the confidence interval included no difference. Compared to controls, CHP participants had higher healthcare utilisation, including specialist outpatient clinic (SOC) visits (RR adj = 1.33, 95% CI: 1.22–1.46), emergency department (ED) visits (RR adj = 1.35, 95% CI: 1.15–1.57), and inpatient admissions (RR adj = 1.18, 95% CI: 1.02–1.37). Healthcare costs for SOC were also higher among CHP participants (CR adj = 1.36, 95% CI: 1.15–1.62), although total healthcare costs did not differ significantly between groups (CR adj = 1.09, 95% CI: 0.91–1.31). The CHP programme had limited effectiveness on chronic disease control within the one-year follow-up period and was associated with increased healthcare utilisation. This may reflect increased screening and engagement with healthcare services. A longer time horizon is needed to evaluate the long-term effects of CHPs.