Advancing the role of nursing in the medical home model

Authors, Primary Tomcavage,J.;Littlewood,D.;Salek,D.;Sciandra,J.
Title Primary Advancing the role of nursing in the medical home model
Periodical Full Nursing Administration Quarterly
Pub Year 2012
Volume 36
issue 3
Start Page 194-202
Abstract The patient-centered primary care model has been positioned to improve patient outcomes, enhance patient satisfaction, and reduce health care costs. The role of nursing in this care transformation is evident in ProvenHealth Navigator-one of the organization's primary care models. ProvenHealth Navigator incorporates primary care practice redesign, including team-delivered care, as the foundation for its model. Case managers, as one of the components of the care team, have demonstrated their value in reducing fragmentation, enhancing care transitions, and coordinating care for the most complex patients.Combining the strengths of a clinical delivery system with the population management expertise of a health plan, ProvenHealth Navigator capitalizes on the strengths of an integrated health care system to stratify the population, enhance access, optimize outpatient treatment, provide near real-time reporting, and deploy additional disease/case management resources for those most in need of additional health care services. Operational since 2006, ProvenHealth Navigator has been associated with significant reductions in all-cause admissions, readmissions, and total cost of care. In addition, quality indicators for chronic conditions and preventive care improved and patient and clinician satisfaction is high. Optimizing the role of primary care teams and focusing on population management services provides one method of improving quality and reducing costs thus increasing health care value.
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Reference Type(s) Journal Article
Topic Tag(s) Comprehensive Care;Care Coordination;Primary Care Workforce Issues;Demonstrations
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