1. Rosenberg, Karen


A new approach to chronic illness could serve as a national model.


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A new program is training nurses in the role of population care coordinator (PCC), with the goal of improving care in high-risk patients and helping primary care practices make the transition into patient-centered medical homes-primary health care settings that facilitate partnerships between individual patients, their personal physicians, and when appropriate, the patient's family.

Figure. Professor Ba... - Click to enlarge in new windowFigure. Professor Barbara S. Turner, DNSc, RN, FAAN (standing), leads a small group discussion on health literacy as part of the PCC certificate program at Duke University School of Nursing. Photo by Les Todd / Duke photography.

In a collaboration between Duke University School of Nursing in Durham, North Carolina, Rutgers College of Nursing in Newark, New Jersey, and Horizon Healthcare Innovations, also in Newark, the PCC certificate program will train 200 nurses over the next two years. Students will complete 12 weeks of classroom, online, and hands-on training based on a curriculum developed by nurses at Duke, followed by a 160-hour preceptorship coordinated by Rutgers.


The first 200 PCCs trained will be placed in primary care practices in New Jersey, but it's anticipated that the curriculum could serve as a national model.


PCCs help to identify high-risk and clinically complex patients in the primary care practice and coordinate care between the medical home and the community. "The focus is on chronic illness management, disease prevention strategies, health promotion interventions, and transitional care needs," says Diane L. Kelly, assistant clinical professor at Duke.


Asked how the role of the PCC differs from that of the public health nurse, Edna Cadmus, clinical professor and specialty director of the graduate leadership track at Rutgers, explains, "Public health nurses are looking at the population level and determining the cause of health problems in a community to find ways to prevent them. PCCs are dealing with the individual patient, creating plans of care with the interdisciplinary team, as well as looking at the population for that practice in aggregate" and identifying high-risk conditions for which outcomes could be improved. They then develop systems and programs to support that high-risk population.


PCCs will play a leadership role in understanding the community and the patients served in that practice, adds Cadmus, and will integrate relevant cultural aspects in their plan of care to ensure that the plan can be followed by the patient and the patient's family. "The goal is to empower patients to manage their own health."


In the short term, some health care costs may rise as patients become more adherent to treatment. In the longer term, however, it's expected that costs will be reduced through reductions in ED visits, hospital admissions, and duplication of services, as well as through the prevention of chronic disease complications.-Karen Rosenberg