Nurses will take the lead in a new program designed to improve chronic care coordination for underrepresented and underserved populations. University of Michigan School of Nursing (UMSN) will expand its partnership with Community Health and Social Services (CHASS) Center by implementing a new program for Registered Nurse Chronic Care Coordinators to lead interdisciplinary teams, which include MDs, pharmacists, support staff, and social workers.
“The nurse leaders will work with the teams to develop a sustainable model of interprofessional care that improve chronic care outcomes,”says UMSN Clinical Associate Professor Donna Marvicsin, PhD, PNP-BC, CDE, who will serve as the project director.
CHASS is located in Southwest Detroit and serves one of the poorest areas of the city, with 68% of the residents living 200% below the federal poverty level. CHASS has identified chronic disease care management as a key area needed to address high levels of health disparities such as diabetes, cardiovascular disease, asthma, poor birth outcomes, poor immunization rates, and mental health issues in their patients.
With a $1.5 million dollar grant from the U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA), UMSN and CHASS will implement the new program using a Patient Centered Care Medical Home (PCMH) model.
“CHASS is a valued partner of UMSN,” says
Kathleen Potempa, PhD, RN, FAAN, dean of UMSN. “With their leadership team, this interdisciplinary approach is a promising opportunity to advance patient-centered care.”
The multi-faceted project will target improving communication and documentation among the interdisciplinary health care team by maximizing electronic health records to alert the team about relevant and timely standards of care. The RN Chronic Care Coordinators will be responsible for coordinating the full implementation and actualization of the system.
“Community-based primary care clinics are very busy, chaotic environments, with many interruptions throughout the day,” says Dr. Marvicsin. “It is hard to find the time to meet as a team to identify needs and delegate tasks. The day quickly becomes a dash to gather the required information at the last minute.”
A third objective aims to ease the demanding schedule by developing a systems-based work plan that will shift the current paradigm of care delivery by having all relevant patient information available for the health care team prior to the patient presenting for care. The RN leader will coordinate with support staff to gather the necessary information and add it to the electronic records system before a patient arrives for their appointment. This proactive approach is designed to improve the patients’ experience of care, foster shared decision-making with patients and enhance interdisciplinary plans of care that can be modified as needed.
Dr. Marvicisin and colleagues believe these changes will lead to improved efficiency and quality of care. In additional, the long-range outcomes are intended to improve the health of an underserved population while also lowering per capita costs of services.
