Managing individuals with chronic health conditions in the primary care setting continues to be a significant challenge in the U.S. health care system. This issue is further compounded for low-income individuals with both mental health and physical health chronic conditions. With the enactment of the Affordable Care Act (ACA), new chronic disease health home opportunities have emerged to address the existing structural and process gaps found in primary healthcare. The nurse’s role is integral to health homes as they empower nurses to play a greater role in improving patient experiences, population health, and lowering healthcare costs. Three research manuscripts presented in this dissertation portfolio focus on improving health care service delivery to individuals with chronic conditions. The first manuscript is a concept analysis of the term care coordination and its application in the primary care setting. The second manuscript is the description of Michigan’s implementation a Section 2703 ACA chronic disease health home, which highlights the importance of the nurse’s health home role. The third manuscript is a mixed methods study aimed to identify the nurse’s perceived role and impact on patients with chronic conditions served in a health home. The study integrated qualitative information obtained from nurse interviews and a focus group with the quantitative data from a sample of 874 patients. The Medicaid Health Home nurse’s role and impact on patients’ health care utilization patterns pre and post implementation are described and related to changes in emergency room use, hospitalizations, office visits, mental healthcare visits, and number of prescription medications.

Date of publication

Summer 8-15-2018

Document Type




Persistent identifier


Committee members

Dr. Danita Alfred, Dr. Susan Yarbrough, and Dr. Catherine Reid


Doctor of Philosophy in Nursing