Submitted by Angela Lunn, (APNP, FNP-C)
Medical Services Manager
At NorthLakes Community Clinic, we help our patients actively remove barriers to wellness to help our communities thrive. Our registered nurse care management program is one of the tools we offer to achieve this goal.
Our RN care managers meet with patients regarding hypertension, diabetes, chronic kidney disease, pain management, medication reconciliation, and mental health concerns. These visits allow the registered nurse to connect with the patient about their concerns regarding their disease or health condition. During this time the patient has the opportunity to ask questions about their condition and how they can manage their health on their own. RN care managers help patients develop goals related to improving their overall health and wellness and provide education on diet, exercise, diseases, medications, and lifestyle changes during these visits. Patients continue to check in with the registered nurse and the two of them will work together to achieve a better overall lifestyle for the patient. Registered nurse care management gives the patient a clinical resource between visits with their NorthLakes provider. This decreases the overall cost for that patient because these types of visits are free for the patient. This also gives the patient an opportunity to get connected with other services NorthLakes has to offer, such as a registered dietitian, behavioral health counseling, community health workers, or peer specialists.
One might wonder how a patient starts seeing a registered nurse for care management. These visits are determined by the provider and the RN team. When a patient has been found the first step is done by the patient’s NorthLakes provider sending a referral to the RN team. The RN will then usually meet with the patient after the visit with the provider. During this visit the RN will go over the reason for care management and discuss overall goals for better health, such as decreasing your blood pressure or A1C. After a goal has been established the nurse will talk with the patient on individual steps to take to achieve this big goal. We call these baby goals. These baby goals are addressed weekly or bi-weekly either by in person visit with the nurse or over the phone. The nurse will discuss with the patient the progress and make adjustments that might be needed for the upcoming weeks. When all goals have been met the patient is then discharged from the program. In addition the nurse will also go over medications with the patient. The nurse will make sure the patient knows what medications they are on along with the correct dose. They will also make sure the patient will be able to set up their medications when home. This looks at their ability to open medications and pill boxes. If the patient does struggle with this the nurse will be able look at additional resources to assist them with proper medication setup.
Overall the goal of NorthLakes registered nurse care management program is to offer a service for patients that promotes better health outcomes while staying connected with our medical team.
NorthLakes Community Clinic currently offers RN Care Management at our medical clinics in Ashland, Hayward, Iron River, Hurley and Minong. To learn more about our medical services, visit nlccwi.org.