Development of a Nursing Care Management Model for Community-Dwelling Individuals with Heart Failure

The aging of the population, with an increasing prevalence of chronic illness, contributes to the need for innovative approaches to delivery of care in the American health care system. Heart failure is the most common chronic illness leading to hospital admission in the United States for persons 65 years of age or older (Knox & Mischke, 1999). Multidisciplinary strategies for management of individuals with heart failure have been shown to reduce hospital readmission rates and mortality (McAlister, Stuart, Ferrua, & McMurray, 2004). My systems change project focused on assisting a group of clinic-based, nurse care managers to develop a new model of care management for high risk, community-dwelling individuals with heart failure who receive care within a large, metropolitan health system. Utilizing a participatory action research process, the care managers were guided to identify needs and opportunities related to the model of care, review best practice evidence from the literature, and come to consensus about implementation of changes to improve the efficiency and effectiveness of their care delivery. Over the course of 11 months, this systems change project contributed to developments that improved systems, workflow, care manager competence, and outcomes for the care management program for individuals with heart failure