On Feb. 1, Rutgers University School of Nursing in Newark, N.J.; Duke University School of Nursing in Durham, N.C., and Horizon Healthcare Innovations, a subsidiary of Horizon Blue Cross Blue Shield of New Jersey, announced the launch of a nursing collaborative to train nurses as population care coordinators in New Jersey. During the next two years, at least 200 nurses will receive education as PCCs to work in a patient-centered medical home program and other population-based health programs.
“The PCCs will serve as pioneers in implementing this new model in the state. Through this unique partnership, we are looking to shift care delivery from an illness model to one of keeping our citizens healthy,” said Edna Cadmus, RN, PhD, NEA-BC, clinical professor and director of the DNP program-leadership track at Rutgers. “The PCCs will serve as linchpins to analyzing data on high-risk patients and developing coordinated plans of care.”
PCCs assess the needs of high-risk patients and close the gaps in their care. Working with primary providers in the medical groups, they follow up on preventive and wellness strategies and arrange appropriate consultations.
“As a PCC, I connected a patient with Alcoholics Anonymous and expedited another patient, who was in acute distress, to receive preadmission testing and cardiac clearance prior to surgery,” said Janet Duni, RN, MPA, PCC in the Vanguard Medical Group in Verona, N.J. “Upon reviewing one patient’s medications, I discovered that he was double-dosing, and we discarded 18 expired medication bottles. After updating his medication list, I enrolled him in an automatic three-month reorder medication service through the Veterans Administration.”