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Nurses’ Growing Role in Chronic Care and Disease Management


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By Debra Wood, RN, contributor

June 4, 2010 - Some might call it the perfect storm: America is aging, people are living longer with conditions that would have killed them in the past, and Congress has recently passed a sweeping health care reform package that opens doors for nurse-led clinics.

“The need [for nurses] will grow tremendously for two reasons: the increase in the elderly from the baby boomers entering this phase of life, and the success of modern medicine – keeping patients alive longer with better medications, surgical techniques, diagnostic imagery, etc.,” said Patricia Starck, DSN, RN, dean of the University of Texas Health Science Center at Houston School of Nursing in Texas.

Bonnie Pilon, DSN, RN
Bonnie Pilon, DSN, RN, anticipates more opportunities for nurses as the number of patients with chronic conditions increases.

Nearly half of all adults suffer from at least one chronic illness, according to data from the Centers for Disease Control and Prevention. And about one in four people with a chronic condition say it limits their daily activity.

“As we age and develop more chronic illnesses related to lifestyle, the number of patients nurses come in contact with who need coaching and mentoring will go up,” said Bonnie Pilon, DSN, RN, senior associate dean of faculty practice for Vanderbilt University School of Nursing in Nashville, Tenn.. “There will be more opportunities for nurses. There will be more people who need managing. It’s a numbers game.”

Chronic conditions are costly to the health care system, according to a 2006 report from the Agency for Healthcare Research and Quality. Nearly half of all health care costs in 1996 were made to care for people with five chronic conditions: mood disorders, diabetes, heart disease, asthma and hypertension.

“The role of nursing is so fitting with the need for coordination and management of the care of people with chronic disease,” added Hila Richardson, RN, DrPH, MPH, BSN, professor and director of the undergraduate, continuing education and community health programs at New York University College of Nursing. “This is one of the things that health reform is trying to address—to keep people out of hospitals and keep them healthier.”

Registered nurses

Intel Health Guide
A patient using the Intel Health Guide, which allows nurses to spot trends and plan interventions. Photo credit: Intel.

As the country begins to address unsustainable, rising health care costs, payors are looking at ways to decrease costs without affecting quality of care. A major component of that effort is prevention, education and management of chronic conditions.

“Nurses are particularly well prepared to manage patients with chronic illnesses, especially when there are multiple, overlapping conditions,” Starck said. “Coordination is especially important to prevent errors and promote optimum care as well as prevent duplication of services and unnecessary costs. Part of successful management is self-care, and nurses are expert at patient teaching and coaching.”

Nurses in every setting have opportunities to educate patients about healthier lifestyle choices. In addition, many nurses work for insurers as disease management specialists, helping beneficiaries understand their self-care and to follow up with providers as directed.

In the coming years, Rosemary E. Mortimer, MSEd, RN, CCBE, an instructor at Johns Hopkins School of Nursing in Baltimore and past president of the Maryland Nurses Association, anticipates nurses will have an expanded role helping patients manage their chronic diseases. She also foresees opportunities for nurses in home care-telehealth positions.

Julie Cherry, RN, MSN, PHN, director of professional services for Intel Digital Health Group in Santa Clara, Calif., helped develop the Intel Health Guide, which collects data from patients in their homes and feeds it into a decision-support tool. It helps nurses spot trends early on and intervene by scheduling a visit for the patient or calling the physician.

Julie Cherry, RN, MSN, PHN
Julie Cherry, RN, MSN, PHN, sees a growing need for services but fewer resources, expanding the need to integrate technology to transform health care. Photo credit: Intel.

With people living longer with multiple chronic conditions and dwindling resources, Cherry said, “this will be the way we will deliver care when we age.”

Payors or group practices cover the cost of installing the unit in the home. Telehealth offers an opportunity to provide a medical home model, Cherry said. The U. S. Department of Health and Human Services calls the Advanced Primary Care model, also known as the patient-centered medical home, a leading model for efficient management and delivery of quality care. It emphasizes prevention, health information technology, care coordination and shared decision making among patients and their providers.

Advanced practice nurses

“Advanced practice nurses’ forte is chronic illness management, because they are seeing so much in their primary and specialty practices,” Pilon said. “They are the front line in trying to maintain people in a secondary prevention mode.”

Michele Rubin, APN, CNS, CGRN, an advanced practice nurse at the University of Chicago Medical Center, also anticipates a larger role for advanced practice nurses with passage of health reform, as more than 30 million additional Americans obtain health insurance and access the system, straining already busy practices.

“Advanced practice nurses will fall into a role of managing chronic disease patients and follow them on an ongoing basis,” said Rubin, explaining that many practices including hers as an inflammatory bowel disease specialist, already function that way. The physician initially sees the patient, and the nurse practitioner follows up and provides education and self-care management information. She changes medication doses and orders and monitors lab work. “I see that model expanding.”

Pilon said specialists also may refer stabilized patients back to primary care. Then if the patient experiences an exacerbation, bump him or her back up to specialty services.

“The volume increases are across the board, because of aging, because of lifestyle,” said Pilon, recognizing also the people who will seek care due to health reform. “Availability of well trained nurses becomes imperative.”

The health reform bill, also known as the Patient Protection and Affordable Care Act, will allow nurse practitioner-led, patient-centered medical homes and full participation of nurses and nurse practitioners in Accountable Care Organizations, which will receive bundled payments to care for patients in a variety of settings.

“Nurses are going to be very helpful in meeting the new demands of primary care,” Richardson said. “The nurse practitioner and the professional registered nurse will have an important role in the future.”


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