In an effort to improve chronic care, AARP is setting out to examine the role of RNs in new healthcare models geared toward patients with persistent conditions, the association reported.
With help from the National Academy for State Health Policy, AARPs Public Policy Institute is forging a series of case studies exploring how RNs are being used in modern ambulatory delivery systems. The first study, Transforming the Workforce to Provide Better Chronic Care: The Role of Nurse Managers in Rhode Island, focuses on enhancing chronic care at the Rhode Island Chronic Care Sustainability Initiative, according to the AARP. A multi-payer medical home initiative, it supports an embedded nurse care manager in each of the 36,000 primary care practices serving more than 220,000 consumers.
The AARP report said the Rhode Island Chronic Care Sustainability Initiative demonstrates how nurse care managers can function in a patient-centered medical home care model.
CSI-RI has found that embedding a nurse care manager in a primary care practice is a critical component of its strategy to improve care and health outcomes for patients with chronic illnesses and/or complex conditions, AARP researchers said.
Among the lessons learned during the five years CSI-RI has been in existence are that the roles of nurse care managers are ever evolving, meaning time a nurse manager devotes to helping build a medical home model could compete with time the nurse can devote to patients, the report said. Another lesson learned from the initiative is that adequate resources and support must be provided to RNs in the form of training for nurse care managers and providers to better integrate nurse care managers into the practice workflow, the report stated.
To overcome remaining challenges, CSI-RI is looking at concepts such as offering behavioral health resources, with South County Hospital in Wakefield, R.I., recently hiring a behavioral health nurse care manager. The initiative also involves revamping education opportunities for RNs.
Nurses also play pivotal roles in five other initiatives and programs examined in the AARP research, including Pregnancy Medical Home Program, North Carolina; Minnesotas Health Care Homes; Hennepin Health in Minnesota; Community Care Organizations Community HUB, Yamhill, Ore.; and CareFirsts Patient-Centered Medical Home, Maryland.
These six initiatives offer replicable opportunities and lessons for other states and/or payers that are developing or considering patient-centered models of primary care delivery, the researchers wrote. All of these initiatives support consumer navigation of complex care systems, understanding of illnesses, and learning self-management skills.