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

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.