When a veteran with diabetes who was experiencing hyperglycemia visited the Overton Brooks VA Medical Center in Shreveport, LA, a nurse practitioner (NP) made adjustments to his medications. But that visit was different from others he had made: he also talked with a team of providers about exercise, diet, and blood glucose self-monitoring, and they discussed what support he would need to make changes in these areas as well.Diabetes Management

After two weeks, Helen Rasmussen, BSN, RN, CDE, a care manager in primary care at the facility, called the patient, who reported his daily blood glucose levels. An NP made further medication adjustments, and Ms. Rasmussen called again in two weeks. “The results were much improved, and he was very happy that he didn’t have to come in to see a provider each time for these changes,” she said.

Ms. Rasmussen has been a primary care nurse with the U.S. Department of Veterans Affairs (VA) for more than 12 years, and until recently, she said, she would not have had the time to make those follow-up calls; her caseload would have been too high. But in 2009 VA secretary Eric Shinseki announced a major push toward more “veteran-centered care” for the 6 million veterans using the system (VA, 2009). One element of that new initiative is the Patient-Centered Medical Home™ (PCMH).

The PCMH is not a new concept. Four decades after the American Academy of Pediatrics developed the concept of a medical home, however, its meaning has evolved. Many now think of the PCMH as a “health home”—a team approach to primary care that involves better care coordination and information systems (including the electronic health record) and gives patients greater access to care and to their providers (including e-mail exchanges). The patient is necessarily at the center of decision making.

The VA’s nearly 65,000 licensed nurses are fundamental to this approach at the VA. “We decided to have a full-time RN [registered nurse] care manager for every full-time primary care provider,” said Catherine Rick, MSN, R.N., NEA-BC, FACHE, the VA’s chief nursing services officer. The RN care manager works with others on a four-person team—including a primary care provider (a physician or an NP) and support staff—to help veterans better manage their illnesses and coordinate transitions in care, such as hospital admission.

Another aspect of the PCMH at the VA is the clinical nurse leader—which, Ms. Rick said, “is probably one of the most transformational roles that the nursing profession has to offer the health care industry.” The American Association of Colleges of Nursing has defined it as a new leadership role for nurses that is neither administrative nor managerial (AACN, 2007); rather, this nurse with a master’s degree supervises the care provided by the team. At the VA, the clinical nurse leader oversees the care provided by more than one team, while the RN care manager focuses on the care provided by just his or her team. The VA intends to employ clinical nurse leaders in all of its medical centers by 2016 (ONS, 2009).

Too few support staff may prevent some facilities from implementing the PCMH, said Colette S. Torres, MSN, R.N., CCM, associate director of primary care, Robert J. Dole VA Medical Center, Wichita, KS, until savings from reduced rates of hospitalization are realized. Also, the VA is measuring outcomes of the PCMH, but data have not yet been released.

Ms. Torres said that what she particularly appreciates about this model “is that we carry our patients through acute and chronic issues.” Under the old model, when a veteran was hospitalized, the primary care providers would wait to see the patient. Now, she said, they visit a veteran in the hospital. “We go up and say, ‘How are you doing? We’re not here to provide your care; we’re here because we’re a part of your team.’ And they absolutely love it.”