The Role of the Nurse in the Chronic Disease Management

บทคัดย่อ

Registered nurses in primary care have been indicated as key in implementing the Chronic Care Model.
This article focuses on the integration of the role of the nurse and nurse’s activities in working with the
Chronic Care Model (CCM). Specifically for each of the model’s elements, this indicates the nurses as key
elements for implementing. The roles of the nurse are presented in six elements: 1) Health care organization
2) Delivery system design 3) Decision support 4) Self-management support 5) Clinical information systems
and 6) Community. Nurse’s activities in chronic disease management can improve quality outcomes and high
quality care.