Integrated Chronic Care Model

The current ANS featured article is titled “Complex Adaptive Systems: A Framework for an Integrated
Chronic Care Model” by Patricia R. Gilman, PhD, MSN, APRN, ACNS-BC. While this article is featured you can download it at no cost from the ANS website. Dr. Gilman shared with us this background about her work:

As a board-certified advanced practice clinical nurse specialist in adult health, my work centers on improving healthcare quality and outcomes within patient, nursing, and systems spheres of influence. Starting my nursing career more than forty-five years ago as an LPN in a rural Minnesota community hospital, I went on to earn an associate degree at the Brainerd Community College in 1986, a bachelor’s degree at Augsburg College in Minneapolis, MN in 2007, and a master’s degree at Winona State University in Winona, MN in 2010. I am a Robert Wood Johnson Nursing and Health Policy Fellow and received my Ph.D. in nursing and health policy from the University of New Mexico Albuquerque in 2018. My research examined the relationships between states’ practice authority, professionalism, autonomy, and interprofessional team function among advanced practice nurses across the U.S. I am a strong advocate for nurses and advanced practice nurses’ ability to practice at their highest level of education and licensure. I have served as a member for the Legislative and Regulatory Committee of the National Association of Clinical Nurse Specialists (NACNS) and am a member of the College of Cardiology, Society of Critical Care Medicine, American Association of Critical Care Nurses, NACNS, American Association of Heart Failure Nurses, and Sigma Theta Tau and Phi Kappa Phi Honor Societies.  

I have a broad clinical background encompassing ambulatory clinics, small, medium, and large academic hospital settings. Currently, I work as a clinical nurse specialist at a hospital within a large healthcare system in California’s Central Valley region. Aside from facilitating improvements in patient care quality, standards of nursing care and nursing practice, and system processes, I support and conduct evidence-based practice and research projects. Research interests and projects include chronic care and heart failure populations, end-of-life care, advanced practice nursing practice, nursing theory, and healthcare policy.

The model presented in my article needs refining and testing to see how significant the effects of external agents are on treatment regimens for individuals with chronic conditions. Given the time and resources to do it, this model depiction is just the beginning of a highly complex system that would be intriguing to explore; the intent is to stimulate thought about future research using Complexity Science, specifically CAS,  to understand complex relationships among populations with chronic conditions.

My other accomplishments include songwriting, music performance, and medium to large-scale stained-glass artwork. With my husband, John, we enjoy motorcycle riding and spending virtual time with our two adult children and two teenage granddaughters who live in Minnesota.