Biomaterial Database

Community care management. Advanced practice nurses as care managers. 2000

C M Waszynski, and W Murakami, and M Lewis

A group of advanced practice nurses partnered with a major insurer in the design and implementation of a care coordination model for high-risk older adults. This article will discuss the process of such an undertaking, highlighting the successes and barriers encountered. The key elements of this program included early identification and regular reassessment of each member's acuity level; fostering close partnerships between individual or teams of APRNs and groups of physicians; and uninterrupted clinical management of high-risk members across the health care continuum. This model was designed to achieve the following outcomes: to support the physician management of high-risk, chronic individuals; to increase or maintain the health of members; and to reduce health care costs. Outcome studies have demonstrated a substantial net savings by decreasing acute care admissions by 54%, reducing hospital days by 42%, and trimming primary care physicians' and specialists' visit costs by 37%. There was a 33% reduction in the overall costs of health care for members enrolled in this program. Physicians and members both rated their satisfaction with the APRN-based model of care as very high.

UI	MeSH Term	Description	Entries
D007587	Job Description	Statement of the position requirements, qualifications for the position, wage range, and any special conditions expected of the employee.	Position Description,Description, Job,Description, Position,Descriptions, Job,Descriptions, Position,Job Descriptions,Position Descriptions
D009720	Nurse Clinicians	Registered nurses who hold Master's degrees in nursing with an emphasis in clinical nursing and who function independently in coordinating plans for patient care.	Clinical Nurse Specialists,Clinical Nurse Specialist,Nurse Specialist, Clinical,Nurse Specialists, Clinical,Specialist, Clinical Nurse,Specialists, Clinical Nurse,Clinician, Nurse,Clinicians, Nurse,Nurse Clinician
D009730	Nursing Assessment	Evaluation of the nature and extent of nursing problems presented by a patient for the purpose of patient care planning.	Nursing Protocols,Assessment, Nursing,Protocols, Nursing,Assessments, Nursing,Nursing Assessments,Nursing Protocol,Protocol, Nursing
D010043	Outcome and Process Assessment, Health Care	Evaluation procedures that focus on both the outcome or status (OUTCOMES ASSESSMENT) of the patient at the end of an episode of care - presence of symptoms, level of activity, and mortality; and the process (ASSESSMENT, PROCESS) - what is done for the patient diagnostically and therapeutically.	Outcome and Process Assessment (Health Care),Donabedian Model,Donabedian Triad,Outcome and Process Assessment,Structure Process Outcome Triad,Model, Donabedian,Triad, Donabedian
D003152	Community Health Nursing	General and comprehensive nursing practice directed to individuals, families, or groups as it relates to and contributes to the health of a population or community. This is not an official program of a Public Health Department.	Nursing, Community Health
D003237	Connecticut	State bounded on the north by Massachusetts, on the east by Rhode Island, on the south by Long Island Sound, and on the west by New York.
D003266	Continuity of Patient Care	Health care provided on a continuing basis from the initial contact, following the patient through all phases of medical care.	Continuum of Care,Continuity of Care,Care Continuity,Care Continuity, Patient,Care Continuum,Patient Care Continuity
D005851	Geriatric Nursing	Nursing care of the aged patient given in the home, the hospital, or special institutions such as nursing homes, psychiatric institutions, etc.	Nursing, Geriatric,Geriatric Nursings,Nursings, Geriatric
D006302	Health Services Research	The integration of epidemiologic, sociological, economic, and other analytic sciences in the study of health services. Health services research is usually concerned with relationships between need, demand, supply, use, and outcome of health services. The aim of the research is evaluation, particularly in terms of structure, process, output, and outcome. (From Last, Dictionary of Epidemiology, 2d ed)	Health Care Research,Medical Care Research,Research, Health Services,Action Research,Health Services Evaluation,Healthcare Research,Research, Medical Care,Evaluation, Health Services,Evaluations, Health Services,Health Services Evaluations,Research, Action,Research, Health Care,Research, Healthcare
D006801	Humans	Members of the species Homo sapiens.	Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man