Nurses as leaders in chronic care

References

Nurse led projects to improve chronic care

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Nurse led projects to improve chronic care

A number of projects in the United States have featured nurses as leaders in the provision of high quality chronic care services.

Pursuing Perfection Project, Whatcom County, State of Washington—Nurses take on the role of clinical care specialist. The philosophy of the project is that the principal manager of a patient with a chronic condition is the person with the disease. The patient is the one making daily decisions about diet, exercise, monitoring, and taking medications. The clinical care specialist, as a member of the care team, partners with those patients having difficulty managing. Clinical care specialist nurses help patients navigate through the health care system, become their advocate, translate medical information into understandable language, and ensure that they are receiving treatment based on current evidence. Many patients are viewed as not doing what their physicians recommended, but when assessed by clinical care specialist nurses, the patients did not understand the disease process or the reasons for the advice they received, and had not been taught the skills and resources needed to do the things that would improve their chronic condition. Patient interactions with a clinical care specialist, compared with patients without such interactions, resulted in decreased hospitalizations and emergency department visits and improved glycosylated haemoglobin levels. The clinical care specialist nurse’s role is to provide a bridge between patient and physician.

Roybal Comprehensive Health Center—At this county run clinic in a Latino neighbourhood of East Los Angeles, patients with poorly controlled diabetes spend six months attending a nurse run diabetes clinic, with nurses providing self management education, medical management, and telephone follow up using protocols created by endocrinologists. Glycosylated haemoglobin levels improve markedly for patients attending the clinic, but when those patients return to traditional primary care (to make room for other patients at the diabetes clinic), diabetic control may falter.

State of Indiana Medicaid Program—Medicaid is the federal state health insurance plan for over 40 million people with a low income in the United States. Indiana Medicaid has implemented a large project using nurse care managers to provide planned care for the 15-20% of patients with diabetes and congestive heart failure whose condition is poorly controlled. In its first year, the percent of patients with HbA1c less than 8 rose from 29% to 59% and the percent with blood pressures below 130/80 increased from 20% to 29%.

Holyoke Health Center in Massachusetts—Nurses are the directors of a programme to train a diabetes team involving community health workers and group education classes for a population of poor Latino patients.

Midwest Nursing Centers Consortium—This association of nursing centres in 14 midwestern states has developed nurse run group health education classes, group physical activity programmes, and social networks for people with obesity and other cardiovascular risk factors.

Project Dulce—In this diabetes programme for low income people in San Diego, California, a nurse led team travels to several community health centres to provide planned care for people with poorly controlled diabetes. Patients cared for by this project have significantly lower rates of hospital admissions and visits to emergency departments than similar patients not enrolled in the project.