New Roles for Nurses in Patient-Centered Medical Homes

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By Sandra McAnallen

The profession of nursing has evolved significantly over the years, much as medicine itself has evolved.  Today, many nurses are still in traditional patient-care-related roles, but career opportunities continue to expand and evolve. 

For example, nurses today provide professional services through an enhanced role in the care coordination process.  This includes placing a unique focus on population health management.

UPMC Health Plan currently employs more than 300 registered nurses. Many of our nurses perform tasks that may have been relatively unfamiliar to many nurses a generation ago.  Foremost among those new roles is that of the practice-based care manager, a core team member who can be vital to the success of the patient-centered medical home.

The concept of the patient-centered medical home focuses on the primary care physician practices, and involves a team approach to care coordination. One of the team members is the practice-based care manager, who coordinates care transitions in coordination with the physician and the team in the delivery of patient-oriented primary care.  

Care managers interact with members/patients in a number of ways, based on provider support/direction or directly to members who request support. The role of the nurse as a care manager has evolved to offer direct contact with members in the provider’s office, in the hospital, and, if necessary, in the member’s home.  Face-to-face interactions have demonstrated an increase in the effectiveness of member education regarding medications, identifications of barriers to management of chronic illness, and promotion of preventive measures, including lifestyle changes needed to support improved health.

At UPMC Health Plan, our practice-based care managers work in high-volume primary care practice sites and serve as a direct link between the primary care physician and the health plan member. In some cases, there is a need for community-based care managers.  The community-based care managers are nurses who work with complex and fragile members who need additional support in order to access health care services. In those cases, the nurse may visit the member in their home and may also accompany them for visits to the primary care physician or specialist, to assist in implementing and developing a plan of care.  UPMC Health Plan care managers also connect a member with needed community resources.  

Learning what it means to be part of a care process that focuses on individual members but delivers results that go well beyond individuals is another new experience for many nurses.  But, it is one that they will become more familiar with in the years ahead as they assist the members in their care.

Sandra E. McAnallen is senior vice president for Clinical Affairs and Quality Performance for the UPMC Insurance Services Division.  The UPMC Health Plan has been an industry leader in the successful implementation and development of the medical home concept.  The concept has been implemented at all UPMC-owned primary care practices, as well as at numerous independent community practices.