Advancing the RN role in Chronic Disease Management

2011 AFHTO conference presentation TITLE: Advancing the RN role in Chronic Disease Management and Prevention in Primary Care PRESENTER (S): Sylvia Scott, Clinical Manager FHT/ORG: Guelph FHT ABSTRACT: Health care systems continue to be challenged to respond effectively to the increasing impact of chronic diseases on population health and health care resources. Using the Ontario Chronic Disease Management and Prevention Model, Guelph Family Health Team (GFHT) responded by integrating advanced registered nurse roles in primary care practice team settings with a goal to improve care for individuals with and or at high risk for chronic conditions. This presentation will discuss a unique interdisciplinary and collaborative model led by RN as the case manager within programs or embedded in the practice team. Their role is provide a holistic approach to the patient/caregiver in order to prevent or manage chronic health conditions by engaging the patient to identify and prioritize their own physical and emotional well-being. The RN also works with the patient/caregiver by monitoring progress and barriers to achieving wellness goals and clinical outcomes. The overall goal is to build patient/caregiver and interdisciplinary team capacity. This is achieved through the RN’s role by triaging in order to facilitate patient focused care, timely provider and community collaboration, patient education, and systems navigation across the entire health care spectrum. Outcomes measures include improved access to primary care, reduced number of emergency room visits and or hospital admissions, improved self-management and improved overall quality of life. Click here to view presentation.