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The Role of Nurses and Continuum Care Support Staff in Chronic Care Management

April 1, 2021
April 1, 2021

The growing role for nurses and other non-physician healthcare professionals for chronic disease care is addressed in the HealthStream webinar, “Treating an Aging Population: An Effective Approach to Addressing Chronic Conditions,” from our three-part series, “Managing Opioids, Pain, and Chronic Disease: Critical Steps in Addressing Population Health.” The webinar was presented by Robin Rose, Vice President of the Healthcare Resource Group, HealthStream, and Robyne Wilcox, Senior Director of Continuum Research, HealthStream.

According to Wilcox, an important healthcare trend “that we're seeing is nurses’ role expanding to help patients and residents manage long term or chronic diseases.” Dovetailing with the growing opportunity in home care and telehealth, nursing roles are extending even further into disease prevention, health promotion, quality improvement, and care coordination. Wilcox shared how “Nurses in every setting are in a unique position to manage patients with chronic illnesses, especially when there are multiple overlapping conditions.”

Because a high percentage of people with chronic illnesses have overlapping conditions, care coordination can be especially important to prevent treatment errors and to promote optimum care. Wilcox added that nurses can play a primary role in preventing “the duplication of services and unnecessary costs that providers are trying to avoid.” Not to be overlooked is patients’ self-care, especially nurses who are helping every patient take responsibility for part of his or her care. Wilcox reminded listeners that nurses are “innately excellent and effective at teaching and coaching patients, putting them in a great position to make a high impact on chronic conditions management.”

Chronic conditions care is also a growing responsibility for CNAs and aides. Wilcox reminded listeners that “the accelerating demographic of older Americans is demanding more healthcare services in general, as well as a more long term of care, much of which is being provided in the home or in community-based settings through home health or daycare facilities.” CMS is encouraging greater use of less expensive settings and providing incentives for providers while “really trying to raise awareness for chronic care management.” According to Wilcox, “the healthcare model that is emerging puts CNAs and home health aides on the front lines of caregiving—they're spending more time with our patients, residents, and clients than any other member of the healthcare team.” Because of the regular close contact, they're in a perfect position, like nurses, to notice subtle changes in an individual's mental or emotional state, as well as in his or her physical condition.

Wilcox closed her presentation by acknowledging the need to “prepare nurses, CNAs, and aides for the growing complexities of caring for the aging population and for dealing with folks with one or more chronic conditions.” Development of care staff has never been more important. She added that training should have a standard of quality that focuses on the best delivery of information possible. Care providers must employ “effective ways to ensure that learners are engaged and that they're retaining the information that’s most important to do their job.” Simultaneously, the information shared “should present the latest evidence based knowledge and best practices.” For Wilcox, the ultimate goal to promote understanding can be met when “training includes assessments and exercises that ensure that learners can translate and apply whatever they learn to their care settings and to the unique needs of each patient.”

To view the full webinar, or learn more about HealthStream’s Population Health Management Library.