Paper
Sunday, November 13, 2005
Care Coordination in Nurse Managed Primary Care
Joan M. Bowman, BSN, MPA, CCM1, Denise M. Soltow, MSN, APRN-BC, FNP2, Kathy M. Forrest, RN, BSN, MA1, and Diane L. McLeod, BSN1. (1) Faculty Practice, Michigan State University College of Nursing, East Lansing, MI, USA, (2) Facutly Practice, Michigan State University College of Nursing, East Lansing, MI, USA
| Learning Objective #1: Identify components of a care coordination model in nurse managed primary care |
| Learning Objective #2: Recognize opportunities for care coordination in patients with chronic disease along the continuum of care within a community context |
The Michigan State University College of Nursing HealthCare Center (NHCC) integrated Care Coordination (case and disease management, Telehealth), which has been identified as a key national strategy for the improvement of safety and quality in healthcare (IOM, 2004), to its existing nursing primary care practice. This session will describe the integration of Care Coordination to a nurse managed primary care center, the collaboration between the advanced practice nurses and the nurse case managers, coordination within the patient's community with community providers, and the impact on patients and their families. The NHCC is a JCAHO-accredited nursing practice arrangement serving over 2,250 clients per year through contracts with the U.S. Dept. of Veterans Affairs and the Ingham County Health Plan (IHP). Care Coordination was designed to improve access to primary healthcare for underserved populations (Veterans and the uninsured) with chronic disease and behavioral health needs. The NHCC population includes 1,700 unique underserved clients with hypertension, diabetes, heart disease, COPD, and depression. Intensity of care coordination services is based on chronic disease, co-morbidity, and other factors. Care Coordination focuses on continuity, client access to healthcare services, and chronic disease outcomes. It increases collaboration and communication among health team members by the nurse case managers' (NCMs) use of healthcare technologies. Information technology, Electronic Health Records (EHR), 24/7 coverage, and Telehealth units in clients' homes maximize NCMs' reach and effectiveness. NHCC provides client-centered, culturally sensitive healthcare in a teaching-learning environment including nursing faculty, an interdisciplinary professional team, and clinical experiences for undergraduate, graduate, and professional students where the Care Coordination model is used in practice.