Libby Scarbrough submitted 2015-02-04

As medicine and technology advance, so do the needs of today’s patient. In order to cope with the changes and growing complexity of healthcare, nurses are taking on more leadership roles in the delivery of medical services. Having worked as a case manager I learned that if you educate a patient on the underlying cause of their symptoms then they are able to manage their care with better outcomes. I am fortunate enough to work in a system whose focus has moved to patient centered care with a multidisciplinary approach, included in that multidisciplinary team is the role of a Clinical Nurse Educator whose primary focus is to oversee the care coordination of a distinct group of patients. This is a supported role by the American Association of Colleges of Nursing, (AACN).

The landscape of health and illness has been changed with the advancement of medical science and technology. Not only are people living longer, they are living with chronic illnesses that would have been fatal twenty years ago. This is true in adults and children, resulting in the need for providers who can manage the on-going health needs of persons of all ages and backgrounds. The necessity for practitioners who focus on the promotion of health and wellness and disease prevention has emerged but also as a means of addressing escalating medical costs. Whether working with older adults, children, minorities, persons with chronic illness, or whole communities, the main theme is promotion and maintenance of health and the improvement of health care outcomes. With the emphasis on prevention and health promotion the PACT works together to plan for the care life-long care and wellness of the patient and care is coordinated through collaboration of all team members. The care team considers all aspects of patient health, with emphasis on prevention and health promotion.

All members of the team have clearly defined roles with a focus on forging trusted personal relationships; the result is coordination of all aspects of health care. PACT uses a team-based approach. The patient is the center of the care team that includes family members, caregivers, and health care professionals—a primary care provider, nurse care manager, clinical associate, and administrative clerk. When other services are needed to meet patient goals and needs, the PACT oversees and coordinates that care. PACT is multidisciplinary with many different team members involved with the care of the veteran.

The Clinical Nurse Educator is a stakeholder in the coordination of care through collaboration where the focus is forgoing trusted personal relationship and the end result is coordination of all aspects of healthcare. And with the implementation of the PACT in the VA hospital system it presents an opportunity to grow in the fast pace healthcare and assure that the veterans are being served individually and not with the individualized care to meet their health needs.