Clinical Nurse Specialists

Leaders in Managing Patients With Chronic Conditions

Mary P. Hansen; Mitzi M. Saunders; Cynthia R. Kollauf; Ludmila Santiago-Rotchford


Nurs Econ. 2019;37(2):103-109. 

In This Article

Emerging Solutions


The American Recovery and Reinvestment Act of 2009 offered financial incentives to healthcare providers and spurred use of electronic health records by all health organizations (CMS, 2009). This explosion of healthcare information has led to a number of virtual programs and ease of access to health information by consumers. Integration of technology includes tools used as interventions such as telehealth and telephone applications used by consumers and providers to manage chronic conditions. Telehealth is reimbursable by CMS for chronic conditions when meeting defined criteria (CMS, 2018).

With the availability of patient portals and mechanisms of delivering health information, there are challenges to its usability. These advancements have led to the concept of population health informatics which entails identifying utilization of data to improve the health of specific populations (Kharrazi et al., 2017). The CNS evaluates the use of technology to serve patient/families for self-management of conditions, nurses in practice for improved patient care, and systems for the ideal retrieval of documented information to determine best care (NACNS, 2010).

Transitional Care

CNSs are successful in developing partnerships from within the acute care setting to facilitate transition of the patient and consistency in the longitudinal plan of care to the ambulatory care setting (Negley et al., 2016). CNSs practicing to the full extent of licensure in the management of patients with chronic conditions mitigate the barriers that exist between hospital and post-acute care efforts. Effective transitional care practices streamline the resources utilized throughout the continuum of the lifespan.