Skip to main content
Journal cover image

Transformation of Care: Integrating the Registered Nurse Care Coordinator into the Patient-Centered Medical Home.

Publication ,  Journal Article
Biernacki, PJ; Champagne, MT; Peng, S; Maizel, DR; Turner, BS
Published in: Population health management
October 2015

The purpose of this quality improvement project was to implement and evaluate a care delivery model integrating the registered nurse care coordinator (RNCC) into a family practice that is certified as a patient-centered medical home (PCMH) by the National Committee for Quality Assurance. The initial target population was the 937 patients with diabetes in the family practice. A pre-post design was used to assess changes in patients' diabetic quality indicators after integrating the role of RNCC using existing staff. This 6-month project compared the following diabetic quality indicators: blood pressure < 140/90 mm Hg, hemoglobin A1c ≤ 7, low-density lipoprotein cholesterol < 100 mg/dL, documentation of smoking cessation counseling, and aspirin prescription if existing vascular disease. Yearly documentation of microalbuminurea level, and filament foot and retinal examination was assessed. Patient and health care team satisfaction also was measured. Care coordination interventions included: telehealth, group visits, standardized individual patient education, as well as creative uses of the electronic medical record for workflow changes, daily huddles, and monthly meetings. The results were positive, statistically significant differences in the pre and post scores for A1c (P = .001, n = 790), foot exam (P = .001, n = 850), and microalbumin (P = .01, n = 850). Post intervention, patient and health care team satisfaction with the RNCC role was high (mean scores ≥3 on a 5-point Likert scale). Integrating the RNCC within a multidisciplinary team in the PCMH had a significant positive impact on diabetic quality indicators. Patient and health care team satisfaction with the RNCC role was high.

Duke Scholars

Altmetric Attention Stats
Dimensions Citation Stats

Published In

Population health management

DOI

EISSN

1942-7905

ISSN

1942-7891

Publication Date

October 2015

Volume

18

Issue

5

Start / End Page

330 / 336

Related Subject Headings

  • Quality Indicators, Health Care
  • Quality Improvement
  • Program Evaluation
  • Patient-Centered Care
  • Patient Satisfaction
  • Patient Care Team
  • Nurse's Role
  • Humans
  • Historically Controlled Study
  • Family Practice
 

Citation

APA
Chicago
ICMJE
MLA
NLM
Biernacki, P. J., Champagne, M. T., Peng, S., Maizel, D. R., & Turner, B. S. (2015). Transformation of Care: Integrating the Registered Nurse Care Coordinator into the Patient-Centered Medical Home. Population Health Management, 18(5), 330–336. https://doi.org/10.1089/pop.2014.0131
Biernacki, Pamela J., Mary T. Champagne, Shane Peng, David R. Maizel, and Barbara S. Turner. “Transformation of Care: Integrating the Registered Nurse Care Coordinator into the Patient-Centered Medical Home.Population Health Management 18, no. 5 (October 2015): 330–36. https://doi.org/10.1089/pop.2014.0131.
Biernacki PJ, Champagne MT, Peng S, Maizel DR, Turner BS. Transformation of Care: Integrating the Registered Nurse Care Coordinator into the Patient-Centered Medical Home. Population health management. 2015 Oct;18(5):330–6.
Biernacki, Pamela J., et al. “Transformation of Care: Integrating the Registered Nurse Care Coordinator into the Patient-Centered Medical Home.Population Health Management, vol. 18, no. 5, Oct. 2015, pp. 330–36. Epmc, doi:10.1089/pop.2014.0131.
Biernacki PJ, Champagne MT, Peng S, Maizel DR, Turner BS. Transformation of Care: Integrating the Registered Nurse Care Coordinator into the Patient-Centered Medical Home. Population health management. 2015 Oct;18(5):330–336.
Journal cover image

Published In

Population health management

DOI

EISSN

1942-7905

ISSN

1942-7891

Publication Date

October 2015

Volume

18

Issue

5

Start / End Page

330 / 336

Related Subject Headings

  • Quality Indicators, Health Care
  • Quality Improvement
  • Program Evaluation
  • Patient-Centered Care
  • Patient Satisfaction
  • Patient Care Team
  • Nurse's Role
  • Humans
  • Historically Controlled Study
  • Family Practice