Coordinated Healthcare Management for Chronic Diseases: Linking Nursing Leadership, Medical Record Systems, and Public Health Administration
Abstract
Background: Chronic disease management in the U.S. is hindered by fragmented services, leading to preventable adverse events, duplicative testing, and rising costs. Coordinated care—anchored in nursing leadership, interoperable medical records, and public health administration—has been linked to better outcomes and system efficiencies.
Aim: To synthesize an integrated framework for coordinated healthcare management of chronic diseases that links nurse-led care coordination, electronic health record (EHR) connectivity, and public health/administrative structures, and to illustrate its clinical impact.
Methods: Narrative synthesis of empirical studies and implementation guidance on care coordination, interprofessional collaboration, and health information technology; application of the Care Coordination Model within an Accountable Care Organization (ACO) to a representative clinical case.
Results: Studies demonstrate that lapses in coordination increase preventable events and missed diagnoses, whereas comprehensive coordination in high-risk populations reduces total medical spending (via fewer admissions and shorter stays). Operational enablers include: clear accountability (designated coordinators/navigators), patient support (education, navigation, social needs), durable referral compacts across settings, and EHR-enabled information exchange (e-referrals, e-consults, shared care plans). A case exemplar showed rapid specialty access, closed-loop communication, and measurable improvement in glycemic control (A1C 7.7%→6.2% in four months) following coordinated cardiology, nursing, and dietetics care. Persistent challenges include fee-for-service misalignment, payer network complexity, and EHR interoperability gaps; value-based contracts and standardized workflows mitigate these barriers.
Conclusion: An integrated, nurse-led, information-connected coordination model—embedded within ACO or similar structures—improves safety, experience, and value for patients with chronic disease while advancing population health goals.
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Authors
Copyright (c) 2025 Alwaleed Hussain Alharbi, Yazeed Mohammed Alanazi, Mohammed Hassan Al Salem, Hadi Bader Alkhazal, Bader Mohammed Alothman, Tahani Abdulhadi Alajmi, Ahmed Saeed Saleh Alzahrani, Younes Abdulkareem Mohammed Alsowelem, Khalid abdulaziz Alotaibi, Ahmed Attiah alzahrani
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