played a vital role in patient health, but now they may also be key in curing an ailing health care system. Nurse leaders have been on the forefront of a new approach to health care delivery known as “nurse-led, team-based care,” a concept that, according to recent studies, provides safe, accessible and affordable health care to millions of Americans. The team- based approach brings together patients, families and care providers from multiple disci- plines—such as nurses, social workers, primary care physicians and therapists—to implement care plans that are comprehensive, coordinated and integrated. For instance, chronically ill or elderly patients in a team-based program might receive coordinated health care overseen by a nurse practitioner working in con- junction with the patient’s family, a physician, an occupational therapist, a counselor or even a regis- tered dietitian. The team-based approach targets the uninsured, underinsured, chronically ill and elderly—groups that account for a disproportionate share of health care spending. Hospital admissions and readmissions are the main drivers of high costs of care for this population, and the American Academy of Nursing says many of these admissions could be prevented with improved coordination and better transitions from the hospital to home. “Nurse-led, team-based care can ensure better health care coordination and outcomes while helping alleviate the demands of Nurse-led, team-based care could help lower medical costs and improvecare. the current economic shortage of workers. For a frequently com- plex, fragmented system that clearly needs reform, effective team-based collaboration can be part of the solution to assure safe and consumer-focused care,” said Jennie Chin Hansen, President of AARP and former Executive Director of On Lok Senior Health Services, the prototype for the fed- eral Program of All-inclusive Care for the Elderly (PACE). On Lok is a fully integrated health plan that delivers medical and long-term, community-based services to those seeking an alter- native to entering a nursing home. The program provides com- prehensive medical and health care, prescription drugs, home- cooked meals and additional ser- vices to patients. It uses an inter- disciplinary team of physicians, nurses, physical and occupational therapists, social workers, dietitians, recreational therapists, home care and health workers, and even drivers. Experts say it and similar programs could be the model for future nurse-led, teambased plans. For more information, visit www.aannet.org.
