2210 Title: A Nurse-Led Center for Chronic Care: Transforming Care in Our Community Date / Time: Thursday, June 10, 2010 at 04:15 PM - 05:45 PM Type: CONCURRENT Level: INTERMEDIATE Sponsor(s): - Speaker(s): Veronica Mansfield; Kathleen M. McKinnon Over 133 million Americans, living in our communities, are afflicted by chronic illness. Compromising their care leads to poor care coordination, lack of follow up, questionable variations in practice, and inadequate training for patient self-management. In Middlesex County, at least 25% of adults report a diagnosis of one or more chronic conditions (2008 Community Health Assessment). To address the problem, nurses at a Magnet hospital manage a Center for Chronic Care Management (CCCM) that is significantly improving clinical, quality of life, and fiscal outcomes of patients with chronic illness. The Center aims to improve coordination of services and access to care by targeting highly vulnerable populations. It serves as an adjunct to primary care practices through its five evidence-based, fully NCQA-accredited, disease management programs: 1)  Air Middlesex for adults with asthma and Little Air for children with asthma; 2) Diabetes Care; 3) Smoking Cessation; 4) Chronic Heart Failure; and 5) Fit for Kids, which is a childhood weight management program. Expert nurse care managers build relationships with patients, primary care physicians, local schools and agencies, and social services that are the basis for transforming chronic care. As change agents within the community, nurse care managers collaborate with area providers to educate citizens, inform legislators, identify gaps in services, and link patients to needed services. The Chronic Care Model, as proposed by Wagner and Bodenheimer, is the holistic framework used by nurses at CCCM to counsel, educate, and connect with patients to build their capacity for self-care. Expert care managers drive chronic care quality improvement by their ability to build integration structures such as CQI teams and clinical practice guideline teams, and provide expert knowledge in chronic care management to the health care team. Improved clinical, financial, and quality of life outcomes related to each disease management program are testimony to the success of the Center for Chronic Care Management. Objectives: Identify three examples of the Center for Chronic Care Management’s (CCCM) integration of Chronic Care Model (CCM) into a community disease management program. Discuss application of national guidelines in each DM program, and methods of promoting the use of evidence-based guidelines in collaboration with the Health Care Professionals (HCP’s) across the Middlesex Hospital (MH) Health Care System. Identify how each DM program is growing and changing to meet the challenges of the health care environment and fiscal constraints.