Nurse case management: collaborative beyond the hospital walls.

In 1989, St. Joseph Medical Center initiated a community-based nursing case management program with two nurses providing care to high-risk, chronically ill, frail elderly patients. This program has expanded to five registered nurses actively following over 120 patients. Target populations now served have expanded to include: frail elderly, high-risk pregnant women, premature infants, AIDS patients, and those with chronic physical and mental illness. The nurse manages and coordinates the care for patients through all settings (community and hospital), brokering services, acting as a patient advocate, and giving traditional hands-on care as needed. Outcomes analysis has shown that, after nursing case management intervention, the patients demonstrated a 71% decrease in admissions to the medical center, a 21% decrease in length of stay, and a 64% decrease in Emergency Room usage. Nursing case management helps to prevent patients' health problems from becoming more complex. Consequently, managing their health effectively requires fewer, less costly resources while achieving improved patient outcomes.