Degree Name

Master of Science in Nursing (MSN)

Document Type

Major Paper


School of Nursing




The burden of chronic disease on our medical system and on society is substantial and adds to the difficulty of managing ever-increasing amounts of patient information as care becomes more complex. It has placed the quality of health care in the United States (US) under scrutiny because of medical errors, lack of coordination, patient frustration and poor outcomes. In response to the many challenges, the Patient-Centered Medical Home (PCMH) model of care was developed and is designed to increase the value of our health care and to improve the experience for the patient. The role of the Nurse Care Manager (NCM) in PCMH to help patients with chronic disease is relatively new, but results in the literature are promising.

In this evaluation study, the literature on effective NCM interventions and attributes is reviewed and summarized. In addition, a small sample of NCMs was interviewed to determine the specific attributes and interventions used by NCMs in PCMH. NCMs are effective in assisting patients in managing chronic disease, engaging and activating the patient, transition of care management, and using electronic medical records (EMR) to track patient outcomes. Collaboration with other clinicians, evidence-based and advanced protocol interventions, advanced education and training, and understanding the social and environmental context of the patient were all found to improve patient care. The findings from the literature as well as the interviews explore the components of effective nurse care management and the challenges for the NCM as the role evolves.

Included in

Nursing Commons