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Transforming the Workforce to Provide Better Chronic Care Series
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New NASHP Publications

  • January 2015

    Part 5 in the Transforming the Workforce to Provide Better Chronic Care:
    The Role of Registered Nurses series.
    Click to see the rest of the series.

    Yamhill Community Care Organization (YCCO), one of 16 coordinated care organizations in Oregon, utilizes a community health nurse to manage its Community HUB program, which helps "super-utilizer" patients more actively engage in their own care and manage their own conditions.

    The program aims to improve health outcomes for these patients by fostering connections to primary care to reduce frequent emergency department utilization. The community health nurse oversees the community health workers who provide direct patient care, identifies potential participants through claims data and referrals, and engages primary care and emergency department providers in the program. In addition to highlighting state policy implications, this brief also showcases an example "day-in-the-life" of Emily Williamson, community health nurse. According to the 2013 performance report released by the Oregon Health Authority, YCCO decreased emergency department utilization from 77.7 percent in 2011 to 58.9 percent in 2013.

    This brief is the fifth in a six-part series, supported by the AARP Public Policy Institute, which explores the evolving role of nurses in new delivery system models.

     

  • January 2015

    Part 4 in the Transforming the Workforce to Provide Better Chronic Care:
    The Role of Registered Nurses series.
    Click to see the rest of the series.

    Minnesota Health Care Homes (HCH), a patient-centered medical home initiative, utilizes regionally-based nurse planners to ensure that HCH practices are meeting specific standards of care that aim to foster improved health outcomes and consumer satisfaction, while also controlling costs. Nurse planners are charged with certifying primary care practices as HCHs and providing practices with resources and technical assistance to help them improve their capacity to function as a HCH.

  • January 2015

    Part 3 in the Transforming the Workforce to Provide Better Chronic Care:
    The Role of Registered Nurses series.
    Click to see the rest of the series.

    Hennepin Health, a safety-net accountable care organization in Minnesota, has begun to integrate primary care into Hennepin County Mental Health Center through a behavioral health nurse care coordinator. The behavioral health nurse care coordinator ensures her patients’ care is comprehensive and coordinated by doing complete assessments of patients’ medical health, behavioral health, and social needs, as well as providing basic on-site medical triaging and patient education.

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