The creation of the ambulatory care management RN model seeks to establish, define, and distinguish the unique role the nurse plays in community care and population health which includes chronic disease management, transitional, and longitudinal care. As the value-based approach continues to impact how healthcare organizations deliver care, the demand for care management services has increased in the ambulatory care setting (Karam et al., 2021). Ambulatory care management registered nurses (ACMRN) play an integral role in providing safe and quality patient care which can lead to improved patient outcomes and satisfaction. In addition, the ACMRNs help reinforce the effective and efficient use of healthcare resources related to the complex care of patients in the community. According to the American Nurses Association (ANA) (n.d.), care coordination is emphasized as being a key tool in improving patient health and patient satisfaction while decreasing overall costs by hospitals, health systems, and payers.
In addition to having a practical use for the nursing model, nurses in an ambulatory care management setting at a large, academic medical center in the Midwest historically felt underutilized and experienced decreased engagement due to inconsistent nursing involvement and leadership. In an effort to establish the team as a professional specialty, a model of care was developed as the framework standardizing the ACMRN practice and making the work more meaningful. The intention with the creation of this model is to increase nursing engagement and retention while decreasing overlap amongst other disciplines within the healthcare setting.
The ambulatory care management RN model consists of five pillars describing how patients, families, invested partners, and the interdisciplinary team are engaged by the nurse care manager. Pillar 1 has a focus on population health using risk stratification tools while addressing social determinants of health and needs assessments. Pillar 2 and 3 focus on longitudinal care by having the tools to effectively differentiate episodic versus longitudinal needs. These pillars require a partnership with the patient, family, and ACMRN to develop and maintain goals through active participation, care plans, and interdisciplinary collaboration. Pillar 4 focuses on transitions of care, a time when patients can be vulnerable. This pillar bridges the gap from discharge to follow up appointment with a focus on symptom management, medication reconciliation, and education. The final pillar in the model highlights the important role the ACMRN plays in chronic disease management. Nurse care managers play a pivotal role in delivering an integrative, evidence-based approach to longitudinal care, patient education, and ongoing support. Tools utilized include risk stratification, assessments, and the development of an individualized care plan.
