Nurse Care Managers and the Medical Home: Better Care for America’s Seniors

According to research from the John A. Hartford Foundation, only 27 percent of America’s senior citizens receive primary care, like the ones found at Chelsea Senior Living: senior assisted living Warren, NJ, according to the medical home model. However, 83 percent of seniors who do receive care according to the patient-centered medical home model say that the experience has improved their overall health. In many home health care situations, nurse care managers are in charge of coordinating a senior’s care team.


Nurses who earn a master’s degree (learn more by clicking here) gain additional training in patient education. For example, a nurse who has an MSN can train patients to manage illness, take medications and maintain healthy habits. According to the Department of Health and Human Services Administration on Aging, the number of elderly persons in America will reach 72.1 million by 2030. The need for Skilled Nursing Therapy and the growth of the medical home model could spell significant career growth for nurse care managers.

Understanding the Patient-Centered Medical Home Model

The patient-centered medical home is a care model that coordinates care from multiple providers for the individual patient. According to the Patient-Centered Primary Care Collaborative (PCPCC), the patient-centered medical home is:

  • Patient-centered. Providers, family members and other in home care team members are expected to respect the patient’s wishes and to provide the patient with complete information for informed decision-making.
  • Comprehensive. In addition to addressing immediate physiological health, the medical home addresses mental health care, Therapy, chronic conditions, preventive care and other patient needs.
  • Coordinated. Care is coordinated between all providers. These can include primary care doctors, hospitals, specialists, home health providers, assisted living facilities, senior home care services and community services.
  • Accessible. Patients have access to providers 24/7. They also have shorter wait times before appointments and can book longer appointment times when needed. You may go to site and see what services are included in a home care service.


What Nurse Care Managers Do

If a senior sees an orthopedist, a physical therapist and a cardiologist in addition to a primary care physician and a home health nurse, those professionals may not know what the other is doing to provide care. For example, the cardiologist may not know which medications the orthopedist has prescribed, and the senior may not be able to provide complete information to each doctor. Also, the senior may tell doctors one thing about daily habits when a home health nurse would provide an objective, observation-based.

Electronic health records (EHR) provide an important medium for sharing patient information, but a nurse care manager can take initiative on the patient’s behalf. For example, the nurse care manager can initiate corrections for potentially dangerous medication combinations, recommend additional types of care for observed conditions or explain the senior’s wishes to family members. The nurse care manager can also provide the senior with assistance related to understanding Medicare OEP and supplemental insurance through the use of a Medicare Advantage Solution software or with assistance regarding affordable prescription drugs.

Nurse Care Managers Are Effective

A study by the RAND Corporation found that patients who had nurse care managers received recommended care more consistently than patients who worked only with their physicians. RAND evaluated 231 high-risk patients across 13 months of primary care visits. With care based only on physician medical records, patients completed needed treatments only 53 percent of the time. Only 12 percent of patients received adequate end-of-life care, and fewer than 40 percent of patients received adequate care for urinary incontinence, dementia and falls. Patients served by a nurse care manager received recommended care 69 percent of the time. RAND published its study in the Journal of the American Geriatrics Society.

In its survey, the Hartford Foundation found that 73 percent of seniors would prefer the patient-centered medical home model. In fact, 48 percent of seniors said that they would change providers to get care according to the medical home model. Elderly patients want to receive care according to this model, and they believe it would improve their quality of life. As the number of aging Americans increases, the number of nurse care managers will have to grow to meet demand.


Building a Fleet of Nurse Care Managers

Any MSN candidate who wants to become a nurse educator should become aware of the patient-centered medical home model and how it benefits patients. Then, they can educate nursing students about available opportunities in care coordination by helping them gain the skills to become nurse care managers.

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