PHN Role in Care Coordination: Development of the Activation and Coordination Team (ACT) Model

Statement of the problem. By 2020, 81 million people will have multiple chronic conditions (MCCs) such as cardiovascular disease and diabetes. Complex, contradictory treatment plans lead to disorganized care, diminished quality of life, and poor outcomes. Effective care coordination improves patient functioning and safety, reduces mortality, and decreases ER visits and hospitalizations.  Care coordination leadership roles for public health nurses (PHNs) are not fully realized in primary care and community settings. This presentation will describe development and implementation of the Rush Activation and Coordination Team (ACT) model for adults with MCCs, and describe elements of PHN role integration in an interprofessional team.

Approach. The nurse/social worker (SW)/physician team met weekly over two years to develop the model, protocols, and screening rating scale. ACT focuses on social determinants of health to drive care coordination interventions, emphasizing patient engagement and active self-care.  Pilot testing of the rating scale and the implementation process will be described.

Product/outcome.  ACT matches resources to psychosocial/ physical complexity through innovative risk stratification. An algorithm assigns patients to Quadrants which differ in emphasis and intensity of team resources. I: Usual care (straightforward medically/socially); II: SW coordinated (straightforward medically; complex socially; III: RN coordinated (complex medically; straightforward socially); IV: RN/SW coordinated (complex medically; complex socially).

Implications. Patient-centered care coordination is a core professional standard and competency for nursing that can optimize PHN expertise. This program demonstrates an integral role for PHNs in an innovative model that addresses integration of primary care and public health, an IOM and ACA priority.