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Developing effective models of care: The role of nurses in chronic disease management

dianagosalvez Diana Gosálvez Prados last modified 1/12/2011 12:49

Patients with multiple chronic disease conditions, such as coronary heart disease (CHD) and poorly controlled diabetes have an increased risk of adverse outcomes and high health care costs. Coexisting depression in addition to these medical conditions is associated with a further increase in morbidity, mortality, disability, and reduced quality of life. Developing effective models of patient care is a key challenge in improving the performance of health care systems. Nurses are particularly well prepared to manage patients with chronic illnesses, especially when there are multiple, overlapping conditions.

Skerratt, S. Developing effective models of care: The role of nurses in chronic disease management. Canadian Journal of Cardiology. 2011; 27(5):362. Avaialable at: http://www.onlinecjc.ca/article/S0828-282X%2811%2901136-6/abstract



Research has demonstrated that evidence-based care management for single conditions improves outcomes. However, recent research (Katon et al., 2010) has demonstrated that an intervention involving nurses providing coordinated care management of multiple conditions (depression, CHD and/or poorly controlled diabetes) via guideline-based, patient-centered management significantly improved disease control in this patient population.

This presentation explores that nature of the nursing contribution to chronic disease management, specifically, a new collaborative care model for patients with depression and CHD and poorly controlled diabetes, or both. The intervention involves proactive follow-up by nurses working collaboratively with physicians, integrating the management of medical and psychological illnesses, and using individualized treatment regimens guided by treat-to-target guidelines. This presentation will be clinically significant for registered nurses, nurse educators, nurse practitioners, clinical nurse specialists and administrators interested in developing effective models of care for patients with multiple medical conditions.

Skerratt, S.

Norte América