Date of Graduation

Fall 12-18-2015

Document Type


Degree Name

Doctor of Nursing Practice (DNP)


School of Nursing and Health Professions

First Advisor

K.T. Waxman, DNP, MBA, RN, CNL, CENP

Second Advisor

M. Bittner, DNP, MPA, RN, CENP

Third Advisor

M. Pettus, M.D., F.A.C.P.



The Patient Protection and Affordable Care Act (2010) has two significant aims: to improve the quality of healthcare and in doing so, to lower the cost of healthcare. The Centers for Disease Control and Prevention (CDC) reports that chronic health conditions, such as diabetes, hypertension, cardiovascular disease, and mental health, which in 2005 affected nearly one of every two Americans, continues to increase (CDC, 2010). Chronic health conditions and lack of access to care are both national and local concerns. These challenges will require the exploration of new models for the delivery of care, as needs shift over time and as the healthcare industry moves from the traditional acute care focus to one of community-based population health focus. The Institute for Healthcare Improvement (IHI) developed the Triple Aim to simultaneously improve population health, improve the patient experience of care, and reduce per-capita cost, as a goal for all healthcare organizations (Stiefel & Nolan, 2012). The position statement released by both the American Organization of Nurse Executive (AONE) and the American Associate of Ambulatory Care Nurses (AAACN) emphasizes the need for nurse leaders to take a lead role in both care coordination and transition management as a substantial way toward the achievement of the Triple Aim (AONE, 2015). The concepts of care coordination, which includes an enhanced plan at discharge, will be embedded into a medical neighborhood setting. Patients will receive comprehensive out-patient medical care assembled under one roof, as well as the social and community services needed to regain and maintain health.

Key Words: care coordination, care navigation, medical neighborhood, chronic conditions.