Community care management. Advanced practice nurses as care managers

Area of Science:

• Geriatric Care
• Health Services Research
• Nursing Practice

Background:

• High-risk older adults often require complex care coordination.
• Existing models may not adequately support chronic disease management across the healthcare continuum.
• Collaboration between advanced practice nurses and insurers can optimize care delivery.

Purpose of the Study:

• To describe the design and implementation of an advanced practice nurse-led care coordination model.
• To evaluate the impact of this model on healthcare utilization and costs.
• To assess patient and physician satisfaction with the new care model.

Main Methods:

• A collaborative model involving advanced practice nurses (APRNs) and physicians was developed.
• Key components included early identification, regular reassessment of acuity, and continuous clinical management.
• Partnerships were fostered between APRNs and physician groups for integrated care.

Main Results:

• Acute care admissions decreased by 54%, and hospital days reduced by 42%.
• Primary care and specialist visit costs were reduced by 37%.
• Overall healthcare costs for enrolled members decreased by 33%, with high satisfaction ratings from physicians and patients.

Conclusions:

• An APRN-led care coordination model can effectively manage high-risk older adults.
• This approach leads to substantial reductions in healthcare utilization and costs.
• The model demonstrates high satisfaction among both healthcare providers and patients.