Weaving Expanded Roles of the RN into Population Management

Andrews, Lois

Purpose:
As Population Health Management evolves, new collaborative roles are emerging which allow nurses the opportunity to practice to the fullest extent of their license. This presentation will explore the changing roles of the nurse in the setting of a Clinically Integrated Network (CIN).

Relevance/Significance:
Registered Nurses employed by the network work collaboratively with providers and physician practices to disseminate evidence-based national guidelines, identify gaps in care, and engage patients to improve their health.

Strategy and Implementation:
Nurses collaborated with over 200 practices in the network to involve physicians and office staff in quality improvement. The network developed two job categories for the RNs: quality coordinators and care managers. A model was developed encompassing the continuum of health and involving both coordinators and care managers. The coordinators worked with the practices and physicians to implement a patient registry, which was then used to identify and close gaps in care. The network care managers collaborated directly with the physicians and patients on a care plan to improve health in high-risk and rising-risk patients. Clinical workgroups, targeting conditions like back pain and headaches have been developed. Patient identification and outreach by the care managers weaves into developing care protocols and physician care, and are supported by interventions from the care managers. Traditional methods of communication as well as tele-health are being used to reach patients.

Evaluation:
Thirteen quality goals were established. The network demonstrated improvement in all and achieved the desired threshold in 10 of the 13. Care managers were able to assist diabetics in decreasing their A1C measure. The care management program was redesigned to allow more specificity. Areas of duplication were identified and eliminated to prevent patient abrasion.

Implications for Practice:
As healthcare evolves, the role of nurses will evolve and expand. The nine dimensions in AAACN's Care Coordination and Transition Management are important, not only for practices, but also for networks and other agencies who are managing the health of populations.