Transforming the Workforce to Provide Better Chronic Care: The Role of Nurse Care Managers in Rhode Island
Part 1 in the Transforming the Workforce to Provide Better Chronic Care:
The Role of Registered Nurses series.
Click to see the rest of the series.
Chronic illnesses are responsible for more than three-quarters of health care spending and 7 out of 10 deaths in the United States—and nearly half of all Americans have at least one chronic illness—according to the Centers for Disease Control and Prevention.
To improve health outcomes, especially for those with chronic illnesses, and help contain health care costs, commercial and public payers broadly support patient-centered medical homes (PCMHs) for delivery of primary care. The PCMH care model emphasizes quality, comprehensive, coordinated, and patient- and family-centered care.
Many PCMH initiatives have found professional care management to be an effective component of a strategy to improve health outcomes by assisting consumers in accessing the medical, behavioral health, social service, and educational resources they need to best manage their care.
The shift to a PCMH model requires that practice staff improve the way they function individually and collectively as a team; the Rhode Island Chronic Care Sustainability Initiative (CSI-RI) is illustrative of how nurse care managers (NCMs) can function in a PCMH model of care. CSI-RI is a multipayer PCMH program that supports 36 practices with 303 providers, including nurse practitioners and physician assistants who serve over 220,000 Rhode Islanders.
The Role of Registered Nurses series.
Click to see the rest of the series.
Chronic illnesses are responsible for more than three-quarters of health care spending and 7 out of 10 deaths in the United States—and nearly half of all Americans have at least one chronic illness—according to the Centers for Disease Control and Prevention.
To improve health outcomes, especially for those with chronic illnesses, and help contain health care costs, commercial and public payers broadly support patient-centered medical homes (PCMHs) for delivery of primary care. The PCMH care model emphasizes quality, comprehensive, coordinated, and patient- and family-centered care.
Many PCMH initiatives have found professional care management to be an effective component of a strategy to improve health outcomes by assisting consumers in accessing the medical, behavioral health, social service, and educational resources they need to best manage their care.
The shift to a PCMH model requires that practice staff improve the way they function individually and collectively as a team; the Rhode Island Chronic Care Sustainability Initiative (CSI-RI) is illustrative of how nurse care managers (NCMs) can function in a PCMH model of care. CSI-RI is a multipayer PCMH program that supports 36 practices with 303 providers, including nurse practitioners and physician assistants who serve over 220,000 Rhode Islanders.
| Attachment | Size |
|---|---|
| Download the Publication | 3.28 MB |
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
