Chronic Disease management RN program in the MTF
RN's can now begin to focus on chronic disease management through patient education and direct patient care. LPN's in the clinic setting are now able to handle many of the telephone consults, complete procedures, give injections and send secured email messages to the patients with the advent of the patient centered medical home model. RN's can begin to better manage and educate diabetic patients, work closely with patients identified as high risk, assist with navigating through the hospital system and focus on meeting more of the patients' health needs by addressing many of the root causes such as poverty, language barriers, depression, polypharmacy and other concerns. The chronic disease management nurse can work with other hospital medical disciplinaries such as pharmacy, case managers, nutrition, social work, behavior health,etc to ensure the patient is treated holistically. The HEDIS measure of decreased ER visits, lower A1C tests and care compliance will improve with the RN more involved in the patient care arena.