Bridging the Healthcare Gap: Understanding Chronic Care Management from Nurses

July 25, 2023   |   Nurses

With her husband in the military, frequent moves and long periods spent as a single mom, Jessica Ruane, RN needed a nursing job to help support her family and care for her kids. Chronic care management seemed like a perfect solution. It wasn’t long before it also became her passion.

“I talk to many patients, some 95 years old, and get advice from them. I love that I’m helping them stay safe, well and out of the hospital,” says Ruane.

What is chronic care management from nurses? 

Chronic care management bridges a healthcare gap outside of physician visits. It’s not unusual in the U.S. for primary care visits to last 15 minutes or less. This makes it challenging for patients to access the information they need to manage chronic diseases. In that time, it’s nearly impossible to address lifestyle changes, diet recommendations or exercise regimens that could improve outcomes for patients with chronic diseases.  

“A physician can only do so much, and often, patients leave the doctor’s office feeling overwhelmed. Then they have all these questions when they’re in the car,” says Ruane. 

That’s where chronic care management from nurses comes in. By partnering with physicians, they’re key to managing patients’ health needs between doctor visits and helping keep patients out of the hospital. 

Typical ways Ruane says she helps patients remotely are answering medication questions, knowing the first signs of inflammation and connecting to a physician when medication adjustments are necessary. 

She’ll also help set up non-medical care that is essential to helping patients stay independent, such as :

  • Setting up transportation 
  • Helping with food and necessity deliveries
  • Connecting with local community resources

Together, this remote support helps patients with chronic diseases stay healthier, live independently and avoid hospital readmissions.

Ruane sees firsthand that having chronic care management from nurses empowers patients. “It’s really about managing the patient to feel their best, have autonomy and take control of their health, ” she says.

Growing need for chronic care management from nurses as the U.S. population ages

In the U.S. today, nearly half the adult population – 133 million Americans – live with a chronic illness, according to the American Hospital Association. Over a quarter of adults have two or more chronic illnesses. Managing them has significant costs on the quality of patients’ lives and on the healthcare system. Chronic disease care is the largest driver of the nation’s $4.1 trillion in annual health care costs, according to the CDC.

Chronic care management from nurses can reduce missed appointments, provide convenient access to health data and improve health outcomes. It’s especially crucial for residents of rural areas who are more difficult to serve with home healthcare.

CCM also improves communication between doctor and patient, increases accuracy in monitoring health conditions over time and supports compliance with treatment plans.

Chronic care management increasingly popular among nurses and nurse practitioners

With the growth of telehealth and the increase of U.S. adults living with chronic illnesses, chronic care management is a growing field for nurses and nurse practitioners. It especially grew during COVID as more physicians’ offices and hospitals needed ways to support many patient visits, and more nurses left hospital jobs due to burnout.

But even before today’s increase in telehealth, chronic care management existed in rural areas. Ruane would call patients located hours from home health services to see if they needed anything, like oxygen, more medication or grocery deliveries.

Training in remote chronic care management requires a different skill set than most clinicians learned in graduate school. Ruane and her team created a training course to certify nurses in remote chronic care management. “There’s a big difference when you go from bedside nursing to telephone or virtual assessment,” says Ruane. 

Future of chronic care management

In the future, Ruane anticipates nurses like her will be able to monitor and support chronic care patients through apps. Even then, though, patients will need personal conversations with empathy to get the support they need to manage the challenges of chronic illnesses. “You can hear a lot when you talk to them and see them that you might otherwise miss,” says Ruane. 

While health apps are expected to play a big role in future chronic care management, Ruane sees the challenges that will come with them. Even today, she still calls some of her patients on home phones because they don’t like cell phones or don’t even have them. “This tech that’s coming could be great, but maybe not for the generation I’m calling right now,” she says. “We’re going to have some growing pains, and it’s going to take time to catch up.”

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