/clinical/,/clinical/nursing-hub/,/clinical/nursing-hub/rn/,

/clinical/nursing-hub/rn/

201612363

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UWHC,UWMF,

Nursing,

Clinical Hub,Nursing Hub

Primary Care RN Care Coordination Program

Primary Care RN Care Coordination Program - Clinical Hub, Nursing Hub

PROGRAM OBJECTIVE

To coordinate care of patients with hypertension, type 2 diabetes and/or depression in order to optimize health and improve overall patient experience. The RN CC acts as an extension of the PCP's care plan, working collaboratively with the interdisciplinary health care team to engage patients in successfully self-managing chronic disease.

PROGRAM DESIGN

RN CCs are located within primary care clinics and offer patient- and family-centered care by providing additional attention and support between health care visits. They proactively reach out to patients to address health goals and build confidence in self-managing their chronic conditions. The goal of this UW Health service is to re-engage patients in our primary care settings who have not actively been seeking care, or who have not actively been focusing on managing their chronic diseases.