Purpose/significance: The incidence of patients with multiple complex chronic conditions is rising.1 Patients with chronic conditions often need additional support to identify and understand personal barriers, engage in healthy lifestyle choices for physical and mental health, manage symptoms, and navigate the health care system. In our family practice care team panel, 58% of patients are over 60 years of age. Providers have limited time to spend with patients. Collaboration with the RN care coordinator bridges that gap through understanding a patient’s capacity to care for themselves in regard to resources, support systems, and burdens of illness and treatment. Chronic care management (CCM) and the utilization of the Instrument for patient capacity assessment (ICAN) tool enhance the RN care coordinator’s ability to understand the needs and concerns of the patient. It is imperative to consider the distinct challenges that a patient faces in order to provide individualized care for patients with chronic conditions. The ICAN tool focuses on the patient’s life situation and the potential burdens of treatment. Identification of burdens provides insight into the patient’s challenges and helps the RN care coordinator formulate a contextualized plan of care.2

Methods: Parameters for inclusion: CCM is offered to patients with two or more chronic conditions expected to last twelve months or until the death of the patient. All patients in the CCM program will complete the ICAN tool at initial enrollment and then at all subsequent visits with the RN care coordinator.

Results/evaluation: A retrospective review of patient self-assessed burdens will be done at enrollment and then at each subsequent visit over a period of one year. Data will be analyzed by number and type of burdens, chronic conditions, age, and gender as well as trends over time while patients are enrolled in CCM.

Implications for practice/learning outcome: Connecting with patients; establishing trusting relationships; meeting them where they are at; and understanding patients’ needs, barriers, and values is advantageous to improving patient self-management and health care outcomes.3

References
1. Leppin, A.L, Montori, V.M & Gionfriddo, M.R. (2015). Minimally disruptive medicine: a pragmatically comprehensive model for delivering care to patients with multiple chronic conditions. Healthcare, 3(1), 50 -63.
2. Boehmer, K.R., Hargraves, I.G., Allen, S.V. et al. Meaningful conversations in living with and treating chronic conditions: development of the ICAN discussion aid. BMC Health Serv Res 16, 514 (2016). https://doi.org/10.1186/s12913-016-1742-6
3. Vanderboom, C.E., Thackery, N. L., & Rhudy, L. M., (2015). Key factors in patient-centered care. Nurse care coordinators’ perspectives. Applied Nursing Research, 28(1), 18-24. https://doi.org/10.1016/j.apnr.2014.03.004

Stacey Barnett MSN, RN

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