Journal of Gerontological Nursing

Public Policy Supplemental Data

Community Models of Care: A Scoping Review

Lindsay Mullins, PhD, FNP-BC; Lisa E. Skemp, PhD, RN, FGSA, FAAN; Meridean L. Maas, PhD, RN, FAAN


Nurse preparation and role in community models of care for older adults is not well documented. The purpose of the current structured scoping literature review was to identify nurse-led or nurse-involved community models of care for older adults, articulate the nurse's role and preparation in the model, and identify Triple Aim policy implications. Literature from 2008 through 2014 yielded 34 models identified in 51 articles. Twenty-one of 34 models were evaluated and none clearly articulated the full impact of a nurse role. Policy implications include: (a) consensus on degree preparation for nurses working in communities with older adults; (b) clearly defined nurse-sensitive measurements that capture the role of nursing in ambulatory and community care; (c) nonrestrictive scopes of practice for gerontological nurses and adult-gerontological nurse practitioners to extend their role beyond clinic settings; and (d) extending beyond value-based payment, which currently is largely physician awarded, and including additional Medicare and Medicaid policy to support nurses, community-level practice, and reimbursement. [Journal of Gerontological Nursing, 42(12), 12–20.]


Nurse preparation and role in community models of care for older adults is not well documented. The purpose of the current structured scoping literature review was to identify nurse-led or nurse-involved community models of care for older adults, articulate the nurse's role and preparation in the model, and identify Triple Aim policy implications. Literature from 2008 through 2014 yielded 34 models identified in 51 articles. Twenty-one of 34 models were evaluated and none clearly articulated the full impact of a nurse role. Policy implications include: (a) consensus on degree preparation for nurses working in communities with older adults; (b) clearly defined nurse-sensitive measurements that capture the role of nursing in ambulatory and community care; (c) nonrestrictive scopes of practice for gerontological nurses and adult-gerontological nurse practitioners to extend their role beyond clinic settings; and (d) extending beyond value-based payment, which currently is largely physician awarded, and including additional Medicare and Medicaid policy to support nurses, community-level practice, and reimbursement. [Journal of Gerontological Nursing, 42(12), 12–20.]

More than 55 million Americans are covered by Medicare, and as Medicare is preserved and advanced for future generations, the focus must be on helping build a better system with smarter spending that keeps individuals healthier (Centers for Medicare & Medicaid Services [CMS], 2015a). Medicare and Medicaid payment policies influence the health care system, and Medicare and Medicaid spending has an impact on federal- and state-led budgets (Altman & Frist, 2015; CMS, 2016b). Current physician-led sick care is an identified barrier to advancement and leaves little monetary support for alternatives that are more health-focused and cost effective (Herzlinger, 2006). Increased numbers of health care consumers and extended lifetimes of those consuming health care highlight the need for provision of services at the individual and community level, allowing older adults to remain in their communities and prevent unnecessary, expensive acute care (CMS, 2015a; Greenfield, 2012). The Affordable Care Act's Triple Aim (care, health, and cost) of health care calls for the formation of new community models of care for older adults and a reconfiguration of current models (U.S. Department of Health and Human Services, 2014). The Institute of Medicine (IOM) Future of Nursing Report recommended an important strategy of using nurses and nurse practitioners to the full scope of their practice to address the Triple Aim (Aiken & Yakusheva, 2014; IOM, 2011).

RNs, practicing to the full extent of licensure, are well positioned to improve health and wellness outcomes through expanded health care models (IOM, 2011). RNs' value, measured as nurse-sensitive indicators (NSIs), are well established in acute care, but are poorly implemented in ambulatory care, as the focus of NSIs is on organizational level issues that fail to identify how nurses improve care delivery and outcomes (Mastal, Matlock, & Start, 2016). NSIs have not yet been developed to address the nurse role in community models of care. Therefore, the purpose of the current structured scoping literature review was to answer the following questions:

  • What are the community models of care for older adults in the United States that are nurse-led or where the nurse is a member of an interdisciplinary team?
  • What is the role of the nurse in these community models of care?
  • What are the implications of the review findings for policy revisions and development?


In 1965, Medicare and Medicaid combined provided health care payment for low-income women, children, older adults, and individuals with disabilities. The availability of coverage for approximately 19.1 million Americans suddenly increased the demand for expanded primary care services (American Association of Nurse Practitioners, 2012). Increasing specialization in medicine led to a decrease in the number of physicians practicing primary care, creating a shortage of primary care physicians. Some physicians coincidentally began mentoring and collaborating with nurses and nurse practitioners, whereas other physicians actively fought the use of nurses in primary care. Thus, a shortage of primary care providers continued, leaving many populations, especially in rural, minority, and low-income areas, underserved in health care. From its inception in the 1960s, Medicare and Medicaid policy has focused on illness and physician reimbursement and has failed to seize the opportunity for providing more cost-effective health promotion and preventive services (Fairman, 2010).

Older adults want to stay in their own homes and communities for as long as possible (AARP Public Policy Institute, 2009). For example, annually 8,357,200 individuals receive support from the five main long-term care services: home health agencies (4,742,500), nursing homes (1,383,700), hospices (1,244,500), residential care communities (713,300), and adult day service centers (273,200) (CDC, 2013; IOM, 2005). Yet, community models of care that include not only illness care for individuals, but also programming for populations to address primary prevention and health promotion, are not new and date back to the late 1800s. Today, the models are absent in many communities and markedly absent in rural, minority, and low income communities (AARP Foundation, 2012).

The discipline of community/public health nursing continues to develop best practices for the provision of primary prevention and health promotion services in collaboration with communities to address social and health issues (Kulbok, Thatcher, Park, & Meszaros, 2012). Although Medicare reimburses for illness and individualized care, such as that provided by the Visiting Nurse Association, public and private funding from local, state, and federal sources was sought for community/public health nursing programming, but with increased privatization of health care, many of these sources of funding have been eliminated.

A focus on reimbursement for medically prescribed illness care does not necessarily take into account community/public health nursing and the unique strengths and needs not only of individuals but the larger communities in which they live. This omission ignores the guidelines of the National Expert Panel on Community Health Promotion, spearheaded by the Centers for Disease Control and Prevention. These guidelines recommend that models of community health include engagement of the community, a focus on wellness/health promotion, and capacity building of the community and workforce (Navarro, Voetsch, Liburd, Bezold, & Rhea, 2006).

For 200 years, the nursing workforce has long been engaged in implementing community and public health promotion interventions, yet, the nurse role is infrequently articulated and evaluated, which leads to confusion or lack of understanding of nurses' roles in development and implementation of community models of care for older adults. The CMS has enacted mechanisms to actualize the Triple Aim and include payment recommendations based on care quality, specifically, in the ambulatory care setting (CMS, 2016a). As a tactic to address the Triple Aim of health care reform, The Future of Nursing Report (IOM, 2011) recommends removing scope of practice barriers and expanding opportunities for nurses to lead and collaborate with other members of health care teams to redesign and improve practice environments.

The current review describes types of community models of care for older adults in the United States that are nurse-led or in which a nurse is a member of an interdisciplinary team. After a brief presentation of the methods used for the review and limitations, a discussion of model characteristics follows and includes: (a) type of model, (b) services offered and evaluated, and (c) the reported role of the nurse. Analyses of implications and recommendations for policy revisions and development are also included.


Due to the largely descriptive nature of reports of community health promotion models of care, a modification of the interpretive scoping review method was chosen to search the literature from 2008 through 2014 (Arksey & O'Malley, 2007; Armstrong, Hall, Doyle, & Waters, 2011; Levac, Colquhoun, & O'Brien, 2010). The steps outlined in the Figure include: (a) identify research questions and search terms, (b) review articles according to inclusion and exclusion criteria, (c) perform a second sort with modified inclusion and exclusion criteria, (d) chart data according to characteristics of the models (Table A, available in the online version of this article), (e) chart data according to the role of the nurse (Table B, available in the online version of this article), and (f) analyze and synthesize the findings.

Methods and search results.


Methods and search results.

Community Models
Community Models

Table A:

Community Models

Model and Nurse Role
Model and Nurse Role

Table B:

Model and Nurse Role

Search Strategies

Health-related electronic databases and the Robert Wood Johnson Foundation White Paper, Innovative Care Delivery Models (Health Workforce Solutions LLC, 2008) were reviewed. After applying the first sort criteria, each remaining report's reference list was searched to identify additional articles.

Models of care were clustered based on unit of care services and physical location of service delivery using inductive content analysis. After evaluating 628 articles, 175 remained. Inappropriate literature persisted, such as articles that described services for populations younger than 65. A second sort using modified criteria yielded 52 articles. After a third sort to cluster articles describing the same model, 35 models of care remained.


Community Models of Care

Models of care are unique structures and processes of organizations or provider groups that deliver health service(s). Community models identified were: outpatient clinic (n = 11, 32%), home-based (n = 9, 26%), geographically defined (n = 8, 24%), and community-engaged clinic (n = 6, 18%) (Table A).

Outpatient Clinics. Outpatient clinics (n = 11) were freestanding or an outpatient arm of acute care hospital systems. Outpatient clinics most frequently provided diagnosis-driven health care services for geriatric conditions (n = 4) or all-inclusive services for individual older adults (n = 7). As a group, out-patient clinic models attempted to address care issues for older adults by creating a coordinated, one-stop-shop for complex care services.

Three of the four specialty/diagnosis-driven outpatient clinic models were evaluated on the effects of early detection and intervention for specific geriatric syndromes: Primary Care Research in Substance Abuse and Mental Health for Elderly (PRISM-E; Azar, Chopra, Cho, Coakley, & Rudolph, 2011; Domino et al., 2008; Kaskie & Buckwalter, 2010; Lee, Mericle, Ayalon, & Areán, 2009; McIntyre et al., 2008; Wiley-Exley, Domino, Maxwell, & Levkoff, 2009), Aging Brain Care Model (Callahan et al., 2011), and Improving Mood-Promoting Access to Collaborative Treatment (IMPACT; Unützer et al., 2008). Upon detection of dementia (Aging Brain Care Model), depression (PRISM-E and IMPACT), and/or substance abuse in older adults (PRISM-E), interdisciplinary teams tailored individual interventions and lessened illness acuity (i.e., measured by fewer neuropsychiatric symptoms).

Four of the seven all-inclusive services were evaluated and the Guided Care model was found to be the most extensively studied for its effects on: (a) the quality of primary care experiences in older adults with multimorbidities (Boyd et al., 2008), (b) provider satisfaction with care (Marstellar et al., 2013), (c) cost utilization (Sylvia et al., 2008), and (d) family caregivers (Wolff et al., 2010). The Guided Care model improved quality of care and quality of physician–patient communication; increased physician satisfaction with communication and management of chronic care; and reduced insurance expenditures, hospital admissions, hospital days, and emergency department (ED) visits. UAMS Senior Health Clinics reported similar outcomes except for financial viability (McAtee, Crandall, Wright, & Beverly, 2009). Program of All-Inclusive Care for the Elderly (PACE) and PACE's academic counterpart, Living Independently For Elders (LIFE) in Pennsylvania and New Jersey, report positive outcomes and continue to recruit older adults and improve satisfaction among older adults and caregivers (Sullivan-Marx, Bradway, & Barnsteiner, 2010).

Patient-centered medical homes (PCMHs) provide support and education for older adults and their families to manage and organize their own care at the level they choose (Agency for Healthcare Research and Quality, n.d.). Fishman et al. (2012) demonstrated the effectiveness of PCMHs; however, Hoff (2010) suggested a one-size-fits-all model could potentially miss specific patient populations.

The Nursing Model for Anticoagulation Management Services and the Heart Failure Resource Center are described as innovative with demonstrated effects in reducing health care costs (Health Workforce Solutions LLC, 2008); however, evaluation data are not reported.

As a group, the outpatient clinic models have tapped into unmet needs for older adults including: (a) refocusing care from provider- to person-centered, (b) accounting for the local context of care, (c) addressing the individual, (d) improving communication and understanding of older adults, and (e) effecting collaborative care for geriatric syndromes and other high incidence chronic conditions.

Home-Based. Home-based models provided care in the home. Nine models delivered geriatric services, including transitional care services (n = 4), primary care (n = 4), or telemedicine (n = 1). Eight of the nine models were systematically evaluated. There were three descriptive studies and one each of the following: randomized controlled trial, retrospective chart review, quasi-experimental study, case study, cost analysis, and post-hoc analysis.

Transitional care services addressed the transition of older adults with multiple chronic conditions from one setting to community-based care, typically from hospital to home. The four transitional care services, After Discharge Management of Low Income Frail Elderly (AD-LIFE), Care Transitions, Transitional Care Model (TCM®), and Chronic Care Coordination models reported reduced acute care use, reduced lengths of stay, and fewer ED visits. AD-LIFE showed improvement in both health and patient satisfaction for those with chronic health conditions (Allen et al., 2011). TCM, led by an advanced practice RN (APRN), was qualitatively evaluated and found older adults and caregivers had the necessary information and knowledge, and care coordination and caregiver experience were improved (Bradway et al., 2012; Naylor & Keating, 2008).

Primary care in the home was reported in the House Call-Home Care Program, the Veterans Administration Home-Based Primary Care (VA-HBPC) Program, Geriatric Resources for Assessment and Care of Elders (GRACE), and the Weydt model. Hospitalization and skilled nursing facility use patterns decreased in older adults served by the VA-HBPC Program (Wajnberg, Wang, Aniff, & Kunins, 2010). The GRACE model improved acute care use and documented improvements in health-related quality of life but no difference in physical functional outcomes (Counsell, 2011; Counsell, Callahan, Tu, Stump, & Arling, 2009). Weydt's model was nurseled and aimed to better address issues of poverty, social isolation, and loneliness, suggesting that a client-oriented rather than provider-oriented model increased providers' and older adults' positive perceptions of care and clinical outcomes (Weydt, 2010). Although telemedicine is on the rise, the one reported telemedicine model (n = 1) was diagnosis-driven for older adults with Parkinson's disease (Joseph, 2009). No evaluation of this model has been reported.

Geographically Defined. Geographically defined models included health care providers (e.g., a group of individuals or health systems) partnering with a geographically located community to offer health care services across the care continuum. Two of the eight geographically defined community models have been evaluated: a Community-Based Participatory Research (CBPR) Lower Mississippi Delta program and the Racial and Ethnic Approaches to Community Health (REACH). Similar to traditional public health models, the recipient of services is a population with a health care problem who reside in a geographically defined area: REACH focuses on diabetes and the CBPR Lower Mississippi Delta program focuses on nutritional needs. These models partner with community members of the designated area and collaboratively develop culturally tailored health programming delivered in community-determined locations. The CBPR Lower Mississippi Delta (Kennedy et al., 2011) and REACH (Hill & Jenkins, 2010; Hossler, Jenkins, & King, 2010; Jenkins, Myers, Heidari, Kelechi, & Buckner-Brown, 2011; Magwood, Jenkins, & Zapka, 2009) models reported high community member engagement with a positive impact on their health choices.

The Samaritan Center (Keller, Brown, & Koerner, 2010), Values Driven System (Gottlieb, Sylvester, & Eby, 2008), Layde model (Layde et al., 2012), Healthy Ager (Matthews, Parker, & Drake, 2012), Collaborative Patient Care Management (Health Workforce Solutions LLC, 2008), and Comprehensive Rural Care Collaborative (Health Workforce Solutions LLC, 2008) partner with communities at the outset of community work to improve buy-in, uptake, and sustainability, and to combine health care and non-health care services, such as retail or skills training centers. To improve community ownership of the services, the local hubs provide a visible community presence. The majority of geographically defined models were not evaluated, but on their websites, they report improved health outcomes and increased satisfaction.

Community-Engaged Models. Engaged models included a hybrid of community input and population statistics to guide program implementation (n = 6). There are six community engaged models that range from being fully engaged (i.e., 11th Street Clinic, Project Dulce, Michener model) to minimally engaged (i.e., Bauer model, Carolina Health Net, and Rebholz model). Fully engaged included a community assessment coupled with community-determined needs to guide health care services. Minimally engaged included provider selection of community services (Table A).

Four of the six community-engaged models were evaluated. Older adults' depression improved (Bauer model; Bauer et al., 2011), and student-run community clinics served the urgent and primary care health needs of an underserved population, improving health outcomes (Rebholz model; Rebholz et al., 2013). Project Dulce demonstrated improved clinical outcomes of diabetes and an economically significant reduction in hospital expenditures for this specific geographic and ethnic community (Philis-Tsimikas et al., 2012). In the Michener model, after assessing the community, neighborhood clinics were developed to meet needs and reduce the number of ED visits, which was a significant savings to the local hospital (Michener, 2013). As a group, fully engaged models were implemented in underserved communities that had pronounced resource needs and poor access to care.

The 11th Street Clinic (fully engaged; Gerrity, 2010) and Carolina Health Net (minimally engaged; Denham, Hay, Steiner, & Newton, 2013) described high levels of local uptake, improved community member health outcomes, and decreased ED visits.

Role of the Nurse

Of the 34 reported models, 21 models were evaluated on a variety of features (Table B). The description of the nurse role included type of preparation (e.g., RN, APRN) and nurses' general skills and activities. Eight models used APRNs and 28 employed a “nurse” without identifying level of preparation. Activities of the APRN included leading the interdisciplinary team (n = 4); education, treatment, and referrals (n = 2); home visits (n = 2); and being a member of the team (n = 2). Nurses without credentials specified (n = 28) participated in leading the team (n = 9); made initial contact, care management/coordination (n = 8); were integral to the team (n = 7); and provided education (n = 2), health coaching (n = 1), and consultation (n = 1).

The nurse role was most clearly defined in the outpatient clinic setting where RNs led coordinated care and least clearly defined when vague descriptors such as “increased autonomy to manage” and “coordinates the care of patients across disciplines and settings” were used (Health Workforce Solutions LLC, 2008, p. 5). The TCM is the only model to articulate the justification of role preparation; more specifically, it identified the need of having an APRN to develop and prescribe therapeutic regimens (Bradway et al., 2012). Four models (i.e., PACE and LIFE, PCMH, TCM, and 11th Street Clinic) either mentioned the importance of the nurses' role or specifically evaluated some component of it in the model (Table A). More often, they discuss the team as a whole but lack clear articulation of the specific nursing functions and value added.


Because little is reported and evaluated in community models of care and, specifically, the nurse's role in the models of care, there is a likelihood that the reported literature does not represent all community models of care. Further, nurse roles are not clearly defined and the reported literature may not represent all nurse roles in community models of care.



In the 1960s, Medicare policy established a focus on episodic, illness care for individuals with physicians as the gatekeepers for health care services reimbursement. Taking into account the historical emphasis on provider-based care in outpatient clinics and home care services (e.g., visiting nurses) and the more recent emergence of community partnerships for health, the reported literature reflects trends toward community-based health promotion models. The most common models were outpatient clinics (32%) followed by home-based (26%), geographically defined (24%), and community engaged (18%). There is a resurgence of community-engaged clinics and geographically defined community models that align closely with the Triple Aim because they are located in the community they serve, develop programming for older adults based on community needs, and offer primary and secondary health care services. This group of models, however, is also the least evaluated, which is likely attributable to the complex nature of working with communities, reimbursement for community-level services, challenges with funding, and the prolonged length of time required to detect population-level trends.

Challenges with the all-inclusive outpatient clinics are: (a) older adults must qualify as being dually eligible for Medicare and Medicaid, (b) each setting can only accept a capitated number of older adults, and (c) recipients may need to travel outside their community to receive services. Major barriers are physical and financial access (i.e., one must report poverty-level incomes). Being unable to access services can impede local uptake once older adults have returned to their communities and may impede sustainability of plans of care.

Community/Public Health Expertise

Only 21 of the 34 models were evaluated and none clearly articulated the full impact of a nurse role including: (a) a clear description of the nurse's skills and activities; (b) cost-saving or cost-generating implications of the nurse role; (c) the impact of individual-, community-, or population-level health outcomes as a result of the nurse role; and (d) the impact of the nurse role on the interdisciplinary team, integral to all members of the health care team practicing to the full extent of their licensure. After 200 years of practice, nurses' educational preparation and credentials remain grossly underreported, reinforcing the belief “a nurse is a nurse” regardless of education and background, and nurse activities and outcomes are buried in medical care (IOM, 2011).


Rigorous evaluation is needed to determine the preparation and role of the nurse in community models of care for older adults. Without these data, it is difficult to determine whether nurses are working to the full extent of their licensure and the impact of the nurse role on community health outcomes. The challenge of capturing population-level trends and performing outcomes evaluation includes identifying the health care providers in the model, the skilled work they do, and how these skills link to process and program outcomes. This challenge is particularly true for gerontological nurses and adult gerontological nurse practitioners (AGNPs), where “nurses” may not be nurses at all, and if they are, may not have preparation in caring for older populations. When the nurse role is not clearly articulated, replicating the model is difficult.

To align with the Triple Aim of health care reform and mobilize nurses in the community to promote health from individual to population, the scope of practice should be well-defined and practice outcomes clearly measured. Policy implications include: (a) consensus on degree preparation for nurses working in communities with older adults; (b) clearly defined NSI measurements that capture the role of nursing in ambulatory and community care; (c) nonrestrictive scopes of practice for gerontological nurses and AGNPs to extend their role beyond clinic settings; and (d) extending beyond value-based payment, which is currently largely physician awarded, and including additional Medicare and Medicaid policy to support nurses, community-level practice, and reimbursement.


The current authors recognize that although not found in this search there are, undoubtedly, a number of public health department programs and community health promotion models for care of older adults that may not include a nurse and/or have not been described or evaluated in the literature. The omission reinforces the critical need to better articulate the preparation and role of the nurse within these population- and community-based models of care.

With the growing proportion and number of older adults with chronic health care needs, the Triple Aim emphasizes building a health care workforce able to provide community-level health promotion, prevention, and management of chronic conditions. The current review described the community health promotion models of care for older adults in the United States that are nurse-led or in which the nurse is a member of an interdisciplinary team. The role of the nurse in these community models of care was described to better understand the relationship between having a nurse on the team and outcomes.

To improve patient and community outcomes, nurses must be allowed to practice to the full extent of their licensure, whether they are RNs or APRNs. However, if not supported with evidence, it is difficult to determine what type of nurse is best suited for a particular practice role, whether barriers exist to nurses' scope of practice, and whether nurse preparation impacts patient and community outcomes.

Although the current research found that nurses are members of teams, the research is consistent with another examination of nursing care models concluding specific data on what nurses do and their impact on interdisciplinary team effectiveness and outcomes is severely lacking (Martsolf et al., 2016). Addressing these concerns remains critical for nurses and nurse researchers to determine whether the preparation of RNs and APRNs has an impact on promoting health, preventing disease and disability, and managing chronic health care for a growing population of older adults.


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Community Models

Outpatient Clinic
  Specialty/diagnosis driven clinics
    PRISM-EAzar, Chopra, Cho, Coakley, & Rudolph (2011) Domino et al. (2008) Kaskie & Buckwalter (2010) Lee, Mericle, Ayalon, & Areán (2009) McIntyre et al. (2008) Wiley-Exley et al. (2009)Secondary data analysis RCT Secondary data analysis
    Aging Brain CareCallahan et al. (2011)Descriptive study
    IMPACTUnützer et al. (2008)RCT
    Chronic CareColeman, Austin, Brach, & Wagner (2009)
  All-inclusive services for individual older adults
    PACE and LIFENational PACE Association (2009) Penn Nursing Science (2016) Sullivan-Marx et al. (2010) Weaver et al. (2008) Wenger et al. (2011)Case study Quasi-experimental Descriptive study
    Guided CareBoyd et al. (2008) Marstellar et al. (2013) Sylvia et al. (2008) Wolff et al. (2010)Non-randomized prospective clinical trial Randomized survey Quasi-experimental RCT
    UAMS Senior Health ClinicsMcAtee et al. (2009)Retrospective analysis
    GanzGanz, Fung, Sinsky, Wu, & Reuben (2008)
  Patient-Centered Medical HomeFishman et al. (2012) Hoff (2010)Pre- and post-survey analysis
    Nursing Model for Anticoagulation Management ServiceHealth Workforce Solutions LLC, 2008
    Heart Failure Resource CenterHealth Workforce Solutions LLC, 2008
  Transitional care services
    AD-LIFEAllen et al. (2011)RCT
    Care TransitionsVoss et al. (2011) Parry & Coleman (2010)Quasi-experimental study Descriptive study
    Transitional Care Model (TCM®)Bradway et al. (2012) Naylor & Keating (2008)Descriptive study
    Chronic Care CoordinationMcGaw (2008)Post-hoc
  Primary care in the home
    House Call–Home Care ProgramLanders, Gunn, & Stange (2009)Descriptive study
    VA Home-Based Primary CareWajnberg, Wang, Aniff, & Kunnis (2010)Retrospective chart review
    GRACECounsell, Callahan, Tu, Stump, & Arling (2009) Counsell (2011)Cost analysis
    Weydt modelWeydt (2010)Case study
  TelemedicineJoseph (2009)
Geographically Defined
  CBPR Lower Mississippi DeltaKennedy et al. (2011)Descriptive
  REACHHill & Jenkins (2010) Hossler, Jenkins, & King (2010) Jenkins, Myers, Heidari, Kelechi, & Buckner-Brown (2011) Magwood, Jenkins, & Zapka (2009)Retrospective analysis
  LaydeLayde et al. (2012)
  The Samaritan CenterKeller, Brown, & Koerner (2010)
  Values Driven SystemGottlieb, Sylvester, & Eby (2008)
  Comprehensive Rural Care CollaborativeHealth Workforce Solutions LLC (2008)
  Collaborative Patient Care ManagementHealth Workforce Solutions LLC (2008)
  Healthy AgerMatthews, Parker, & Drake (2012)
Community Engaged
  Fully Engaged
    11th Street ClinicGerrity (2010)
    Project DulcePhilis-Tsimikas et al. (2012)Descriptive
    MichenerMichener (2013)Descriptive
  Minimally Engaged
    BauerBauer et al. (2011)Quasi-experimental
    Carolina Health NetDenham, Hay, Steiner, & Newton (2013)
    RebholzRebholz (2013)Retrospective chart review

Model and Nurse Role

ModelNurseAPRN or SpecialistActivities
Outpatient Clinic
  PRISM-EXSpecialistNurse: care manager Specialist: counselor and referral
  Aging Brain CareXEducation, treatment, and referrals
  Chronic CareXIntegral care team
  PACE and LIFEXCare manager
  Guided CareXLeads interdisciplinary team
  UAMS Senior Health ClinicsXPart of interdisciplinary team
  GanzXCare coordination
  Patient-Centered Medical HomeX24-hour consulting Part of the interdisciplinary team
  Nursing Model for Anticoagulation Management ServiceXLead
  Heart Failure Resource CenterXLead
  AD-LIFEXXAPRN: lead team Nurse: care manager
  Care TransitionsXHealth coach
  Transitional Care Model (TCM®)XLeads
  Chronic Care CoordinationXInitial contact after “trigger” event
  House Call–Home Care ProgramXHome visits
  VA Home-Based Primary CareXHome visits and collaborating care
  GRACEXPart of the interdisciplinary team
  Weydt modelXLead
  TelemedicineXIn-person education
Geographically Defined
  CBPR Lower Mississippi DeltaXNurse: educational sessions LPN: collect blood samples
  LaydeXPart of multidisciplinary team
  The Samaritan CenterXAuthor and lead
  The Values Driven SystemXCare coordinator
  Comprehensive Rural Care CollaborativeXPart of a team
  Collaborative Patient Care ManagementXPatient care coordinator (Physician co-chair)
  Healthy AgerXLead
Community Engaged
  Bauer modelXXAPRN: leads collaborative team Nurse: care manager
  11th Street ClinicXLead interdisciplinary team
  MichenerXMember of health care team
  Project DulceXLead
  RebholzXPart of interdisciplinary team
  Carolina Health NetXPart of collaborative team

Dr. Mullins is Associate Professor, Our Lady of the Lake College, Baton Rouge, Louisiana; Dr. Skemp is Professor, Loyola University–Chicago, Chicago, Illinois; and Dr. Maas is Professor Emerita, University of Iowa, Iowa City, Iowa.

The authors have no potential conflicts of interest, financial or otherwise.

Address correspondence to Lindsay Mullins, PhD, FNP-BC, Associate Professor, Our Lady of the Lake College, 5414 Brittany Drive, Baton Rouge, LA 70808; e-mail:


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