1. COORDINATING RESOURCES IN INDIAN COUNTRY
Albuquerque Area Indian Health Service
Acoma-Canoncito-Laguna Service Unit
Melissa Y. Wyaco, RN, BSN
Chief Nurse Executive

2. ACOMA-CANONCITO-LAGUNA SERVICE UNIT

3. DEFINING AMBULATORY CARE NURSING

4. American Academy of Ambulatory Care Nursing (AAACN)
“The Standards promotes effective clinical and administrative management of increasingly complex ambulatory care RN roles and responsibilities in a changing health care environment.”

5. INDIAN HEALTH SERVICES (IHS)

6. “Ambulatory nursing services encompasses outpatient and emergency services provided to the client and family in an ambulatory care setting that may be located in a free standing clinic, hospital outpatient department, health center or station. A professional registered nurse shall be responsible for the administration, delivery and evaluation of the ambulatory nursing care and services. A professional nurse shall be in the unit during all regularly scheduled hours of operation.”

7. PRIMARY CARE SETTINGS Chronic Disease management Population base
Scope of Practice
Goal: Enhance the patient experience, support population health and improve the work environment within IHS
Chronic Disease management
Population base
Public Health
Patient Centered Medical Home recognition
Joint Commission

8. DEVELOPMENT OF IMPROVING PATIENT CARE

9. IMPROVING PATIENT CENTER PROGRAM
IHS launched IPC
Why
Quality Outcome Measures
Evidence Base Practices
Best Practices

10. IPC
VIDEO

11. PCMH

12. JOURNEY TO PCMH
IPC
initiative
Leadership
Challenges
Outcomes
PCMH

13. NUSING SKILL SETS

14. PCMH Assessment-Team Membership & Responsibilities (PC. 02. 04
PCMH Assessment-Team Membership & Responsibilities (PC /EP 1, 2,4,8,10)
Nurse role in PCMH
Case Management
Care Coordination
Nurse Specialist
Diabetes Nurse Educator
Continuum of Care
Community Based
Public Health

15. PCMH Assessment-Team Membership & Responsibilities (PC. 02. 04
PCMH Assessment-Team Membership & Responsibilities (PC /EP 1, 2,4,8,10)
Interdisciplinary Team
Behavior Health
Physical Therapy
Nutritionist
Optometry
Audiology
HIM
Purchased Referred Card
Business Office
Laboratory
Radiology
Medical staff
Nurse Practitioners
Physician Assistants
Mid-Wives

16. PCMH Assessment- Care Coordination (PC.02.04.05/EP 5,6,7,8)
Patient management
Appointments
Referrals
After care
Equipment

17. PCMH FOUNDATION

18. WE MOVE FORWARD

19. QUESTIONS?