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October 24, 2017

Cleveland Clinic's nurse-led, team-based approach to chronic care

Daily Briefing

    To better manage patients' chronic conditions, Cleveland Clinic runs seven nurse-led Chronic Care Clinics that take a team-based approach to helping patients stay out of the ED, according to the Clinic's Consult QD.

    The goal of clinics

    CDC data show that chronic diseases cause seven out of 10 deaths and cost the U.S. health care system around $1.7 trillion annually. At the Chronic Care Clinics, nurses seek to manage these diseases, including asthma, chronic obstructive pulmonary disease (COPD), diabetes, and heart disease.

    The clinics help patients manage their conditions and related exacerbations in an outpatient setting. The clinics also offer preventive care services like hypertension management, smoking cessation programs, and vaccinations.

    "We see those patients, follow their disease closely and intervene as needed," Kristine Adams of the Clinic's Care Management and Ambulatory Services said. She added, "Serving patients in the clinics prevents them from having to go to the emergency department, where it is less convenient and more expensive to be treated."

    How the clinics work

    Clinics are typically staffed with a nurse practitioner and two to three RNs who use a team-based approach. Patients who visit the clinic are first seen by an RN, who examines and treats the patient based on their individualized care plan. If the RN identifies any new problems or developments, the patient will then see the nurse practitioner.

    "The caregivers manage the patients together and know them all collectively," said Adams. "It's like a village that surrounds the patient." Adams emphasizes that the Chronic Care Clinics seek to provide relationship-based care. "What would success look like for each patient?" Adams said. "Is it [being able to play an instrument], staying off dialysis, or going to a great-granddaughter's wedding? Whatever it is, that's what we aim for" (Consult QD, 10/13).

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