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Show Creating a Nurse Care Manager Model to Implement at the South Main Clinic for Care of High-Risk Patients of the BirthCare HealthCare (BCHC) Team Alma Gil, BSN, RN Key Findings: There is a need for a nurse care manager at the University of Utah South Main Clinic to provide education, monitoring, follow-up, referral, and coordination of care for high-risk maternity patients of the BirthCare HealthCare team. Background The BirthCare HealthCare (BCHC) midwifery team at the University of Utah South Main Clinic (SMC) serves mainly a population of primarily underserved, uninsured, non-English speaking pregnant women. Currently there are gaps in care for high-risk patients with the following health conditions: • Gestational diabetes/prediabetes • Gestational hypertension/chronic hypertension • Iron deficiency • History of a preterm birth The purpose of this project is to create a nurse care manager model that best supports the high-risk maternity population of the BCHC team. Methods • Needs assessment of clinic workflow, current strategies, and risk stratification of patient mix: • Staff interviews • Chart audit • Review of evidence-based care management literature and models. Results [Image] • Needs assessment identified gaps in care: • Missed tracking by healthcare team of patient home blood sugar and blood pressure logs • No designated staff member to provide diabetes management training • Concern for unfunded patients that need an iron transfusion or weekly progesterone treatment • Chart Audit identified: • 119 total BCHC patients at SMC • 61% of patients have 1 or more high-risk conditions • GDM-16%, GHTN-11%, PTB-6%, Low iron-48%, SAB1% • Nurse Care Manager Model created Conclusions • There are patient care gaps for the high-risk population of the BCHC team at the SMC • A Nurse Care Manager Model was created to help support care gaps • Results of implementing nurse care manager model are measured through patient-care outcomes COLLEGE OF NURSING |
