Nurse-Led Care Coordination in a Transitional Clinic for Uninsured Patients With Diabetes.

Purpose/objectives: The purpose of this article is to inform the reader of the practice of the registered nurse care coordinator (RNCC) within an interprofessional, nurse-led clinic serving uninsured diabetic patients in a large urban city. This clinic serves as a transitional care clinic, providing integrated diabetes management and assisting patients to establish with other primary care doctors in the community once appropriate. The clinic uses an interprofessional collaborative practice (IPCP) model with the RNCC at the center of patient onboarding, integrated responsive care, and clinic transitioning.

Primary practice setting: Interprofessional, nurse-led clinic for uninsured patients with diabetes.

Findings/conclusions: Interprofessional models of care are strengthened using a specialized care coordinator.

Implications for case management practice: Care coordination is a key component in case management of a population with chronic disease. The RNCC, having specialized clinical expertise, is an essential member of the interdisciplinary team, contributing a wide range of resources to assist patients in achieving successful outcomes managing diabetes. Transitional care coordination, moving from unmanaged to managed diabetes care, is part of a bundled health care process fundamental to this clinic's IPCP model. In a transitional clinic setting, frequent interaction with patients through onboarding, routine check-ins, and warm handoff helps support and empower the patient to be engaged in their personal health care journey.