Nurse-Led Care Coordination in a Transitional Clinic for Uninsured Patients With Diabetes

Sarah Coiner; Alison Hernandez; Paula Midyette; Bela Patel; Michele Talley

doi:10.1097/NCM.0000000000000732

Nurse-Led Care Coordination in a Transitional Clinic for Uninsured Patients With Diabetes

Prof Case Manag. 2024 Apr 1. doi: 10.1097/NCM.0000000000000732. Online ahead of print.

Authors

Sarah Coiner^{1

2

3

4

5}, Alison Hernandez^{1

2

3

4

5}, Paula Midyette^{1

2

3

4

5}, Bela Patel^{1

2

3

4

5}, Michele Talley^{1

2

3

4

5}

Affiliations

¹ Sarah Coiner, DNP, RN-BC, CNL, CNE, CDCES, is an instructor at The University of Alabama at Birmingham (UAB) School of Nursing (SON) and a certified clinical nurse leader. She holds a faculty practice as a nursing care coordinator at the UAB PATH Clinic and is a certified diabetes care and education specialist.
² Alison Hernandez, PhD, MPH, RN, is a nurse clinic manager at the UAB PATH Clinic. She received a PhD in Public Health at Umea University, Sweden, and completed her BSN at UAB. Her doctoral research focused on nurses' performance in rural Guatemala. Her career interest is developing the nursing profession's role in addressing health inequities.
³ Paula Midyette, MSN, CCNS, CCRN-K, CNE, CDCES, is an adjunct didactic instructor at UAB SON and is a certified adult health clinical nurse specialist. She holds a faculty practice as a nursing care coordinator at the UAB PATH Clinic and is a certified diabetes care and education specialist.
⁴ Bela Patel, DNP, CRNP, NP-C, is a certified adult-gerontology primary care nurse practitioner. Currently, she works as an assistant professor at UAB SON and maintains her faculty practice as the lead nurse practitioner at the PATH Clinic that specializes in providing care to the indigent population with diabetes.
⁵ Michele Talley, PhD, ACNP-BC, FNAP, FAANP, FAAN, is Professor, Associate Dean for Clinical and Global Partnerships at UAB SON, and Director of the UAB PATH Clinic. Her focus is on transforming care of diabetes using innovative models.

PMID: 38557562
DOI: 10.1097/NCM.0000000000000732

Abstract

Purpose/objectives: The purpose of this article is to inform the reader of the practice of the registered nurse care coordinator (RNCC) within an interprofessional, nurse-led clinic serving uninsured diabetic patients in a large urban city. This clinic serves as a transitional care clinic, providing integrated diabetes management and assisting patients to establish with other primary care doctors in the community once appropriate. The clinic uses an interprofessional collaborative practice (IPCP) model with the RNCC at the center of patient onboarding, integrated responsive care, and clinic transitioning.

Primary practice setting: Interprofessional, nurse-led clinic for uninsured patients with diabetes.

Findings/conclusions: Interprofessional models of care are strengthened using a specialized care coordinator.

Implications for case management practice: Care coordination is a key component in case management of a population with chronic disease. The RNCC, having specialized clinical expertise, is an essential member of the interdisciplinary team, contributing a wide range of resources to assist patients in achieving successful outcomes managing diabetes. Transitional care coordination, moving from unmanaged to managed diabetes care, is part of a bundled health care process fundamental to this clinic's IPCP model. In a transitional clinic setting, frequent interaction with patients through onboarding, routine check-ins, and warm handoff helps support and empower the patient to be engaged in their personal health care journey.