Diabetes Nurse Case Management Training Program: Enhancing Care Consistent With the Chronic Care and Patient-Centered Medical Home Models

摘要

Many patients remain at high risk for diabetes complications because of poor glycémie control.14 Case management, defined as the assignment of authority to a professional (the case manager) who is not the provider of direct health care, but who oversees and is responsible for coordinating and implementing care,5 is an effective intervention to improve glycémie control.6'8 The use of nurses as case managers (NCMs) for patients with poor glycémie control follows the Chronic Care Model (CCM) of collaborative care in that a proactive approach is undertaken by the health care team to improve outcomes.9 Similarly, the use of NCMs is aligned with the core principles of the Patient-Centered Medical Home (PCMH) model (e.g., enhanced access and coordinated and comprehensive care).10 However, research findings have not always shown that NCMs improve clinical outcomes.12 A recent evaluation of the Kaiser Permanente Northern California's care management program suggests that an important consideration for achieving success in clinical outcomes is ensuring that the NCM program encourages needed intensification of medication regimens for patients.13 However, finding and hiring nurses previously trained in glucose pattern management, including having the knowledge to make specific recommendations about adjustment of hypoglycemic medications, may present a barrier to health care organizations seeking to implement an effective NCM program. [...] during follow-up, NCM patients improved their AlC values to a slightly greater extent (9.1 ± 1.6 vs. 9.4 ± 1.6%, P < 0.01).n (Only two were CDEs before the NCM program.) In addition, registered dietitians at the clinic sites who also teamtaught the diabetes classes and saw patients for medical nutrition therapy were motivated by the success of the program. Show less