Part 5 in the Transforming the Workforce to Provide Better Chronic Care:
The Role of Registered Nurses series.
Click to see the rest of the series.
Yamhill Community Care Organization (YCCO), one of 16 coordinated care organizations in Oregon, utilizes a community health nurse to manage its Community HUB program, which helps "super-utilizer" patients more actively engage in their own care and manage their own conditions.
The program aims to improve health outcomes for these patients by fostering connections to primary care to reduce frequent emergency department utilization. The community health nurse oversees the community health workers who provide direct patient care, identifies potential participants through claims data and referrals, and engages primary care and emergency department providers in the program. In addition to highlighting state policy implications, this brief also showcases an example "day-in-the-life" of Emily Williamson, community health nurse. According to the 2013 performance report released by the Oregon Health Authority, YCCO decreased emergency department utilization from 77.7 percent in 2011 to 58.9 percent in 2013.
This brief is the fifth in a six-part series, supported by the AARP Public Policy Institute, which explores the evolving role of nurses in new delivery system models.