Team Based Care Across Care Continuum

The fundamental method to improve the health of our population is one patient/family at a time. Certainly we can and must influence and help manage and coordinate population health: reducing obesity, improving nutrition, attacking poverty and improving health management of chronic diseases like diabetes, COPD, CHF, and arthritis.  Nurses in the medical home model affect individual clinical and aggregate public health outcomes through helping patients and families effectively manage and engage in their problems to achieve their own short term and longer term goals.  Nurses knowing our patients and their social support unit, whether in the ICU or the patient’s home and ambulatory care clinic, makes the difference in our ability to coordinate the healthcare team and available resources. 
This article is an excellent example of what healthcare reform should bring to our communities!


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