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care coordination, chronic illness, nurse care coordinator, patient-centered medical home, reimbursement



  1. Henderson, Susan BS, MA, RN
  2. Princell, Catherine O. MS, RN
  3. Martin, Sharon D. PhD, MSN, RN


Overview: The passage of the Patient Protection and Affordable Care Act (ACA) of 2010 has helped reshape primary care by funding the development of care approaches that better integrate and coordinate services, such as the patient-centered medical home (PCMH). Primary care practices that adopt this model offer the comprehensive, patient-centered care that is especially needed by those who are chronically ill. In a significant change from traditional reimbursement policies, the ACA offers incentives and resources that allow for care coordinators-who are typically nurses-to be recognized and paid for their efforts.


This article discusses the guiding principles of the PCMH model, nurse care coordination, reimbursement and implementation, cost-effectiveness and quality improvement, and the need for greater nurse advocacy. Finally, the experience of a care coordinator in a rural PCMH in Maine is presented