Breakthroughs in medical science and technology, combined with shifts in lifestyle and demographics, have resulted in a rapid rise in the number of individuals living with one or more chronic illnesses. Comprehensive Care Coordination for Chronically Ill Adults presents thorough demographics on this growing sector, describes models for change, reviews current literature and examines various outcomes.
Comprehensive Care Coordination for Chronically Ill Adults is divided into two parts. The first provides thorough discussion and background on theoretical concepts of care, including a complete profile of current demographics and chapters on current models of care, intervention components, evaluation methods, health information technology, financing, and educating an interdisciplinary team. The second part of the book uses multiple case studies from various settings to illustrate successful comprehensive care coordination in practice. Nurse, physician and social work leaders in community health, primary care, education and research, and health policy makers will find this book essential among resources to improve care for the chronically ill.
Editors and Contributors ix Acknowledgments xv Introduction xvii Part 1 Theoretical Concepts 1 Chronic illness 3 Paul Shelton, EdD, Cheryl Schraeder, RN, PhD, FAAN, Michael K. Berkes, BS, MSW Candidate, and Benjamin Ronk, BA 2 Overview 25 Cheryl Schraeder, RN, PhD, FAAN, Paul Shelton, EdD, Linda Fahey, RN, MSN, Krista L. Jones, DNP, MSN, ACHN, RN, and Carrie Berger, BA, MSW Candidate 3 Promising practices in acute/primary care 39 Randall S. Brown, PhD, Arkadipta Ghosh, PhD, Cheryl Schraeder, RN, PhD, FAAN, and Paul Shelton, EdD 4 Promising practices in integrated care 65 Patricia J. Volland, MSW, MBA, and Mary E. Wright 5 Intervention components 87 Cheryl Schraeder, RN, PhD, FAAN, Cherie P. Brunker, MD, Ida Hess, MSN, FNP-BC, Beth A. Hale, PhD, RN, Carrie Berger, BA, MSW Candidate, and Valerie Waldschmidt, BSE 6 Evaluation methods 127 Robert Newcomer, PhD, and L. Gail Dobell, PhD 7 Health information technology 141 David A. Dorr, MD, MS and Molly M. King, BA 8 Financing and payment 167 Julianne R. Howell, PhD, Robert Berenson, MD, and Patricia J. Volland, MSW, MBA 9 Education of the interdisciplinary team 191 Emma Barker, MSW, Patricia J. Volland, MSW, MBA, and Mary E. Wright Part 2 Promising Practices Section 1 Primary Care Models 10 Coordination of care by guided care interdisciplinary teams 209 Chad Boult, MD, MPH, MBA, Carol Groves, RN, MPA, and Tracy Novak, MHS 11 Care management plus 221 Cherie P. Brunker, MD, David A. Dorr, MD, MS, and Adam B. Wilcox, PhD 12 Medicare coordinated care 229 Angela M. Gerolamo, PhD, APRN, BC, Jennifer Schore, MSW, MS, Randall S. Brown, PhD, and Cheryl Schraeder, RN, PhD, FAAN Section 2 Transitional Care Models 13 The care transitions intervention 263 Susan Rosenbek, RN, MS, and Eric A. Coleman, MD, MPH 14 Enhanced Discharge Planning Program at Rush University Medical Center 277 Anthony J. Perry, MD, Robyn L. Golden, LCSW, Madeleine Rooney, MSW, LCSW, and Gayle E. Shier, MSW Section 3 Integrated Models 15 Summa Health System and Area Agency on Aging Geriatric Evaluation Project 293 Kyle R. Allen, DO, AGFS, Joseph L. Ruby, BA, MA, Susan Hazelett, RN, MS, Carolyn Holder, MSN, RN, GCNS-BC, Sandee Ferguson, RN, BBA, MS, Fellow, and Phyllis Yoders, RN, BSN 16 Program of All-Inclusive Care for the Elderly (PACE) 303 Brenda Sulick, PhD, and Christine van Reenen, PhD Section 4 Medicaid Models 17 Introduction to Medicaid care management 317 Allison Hamblin, MSPH, and Stephen A. Somers, PhD 18 The Aetna Integrated Care Management Model: a managed Medicaid paradigm 325 Robert M. Atkins, MD, MPH, and Mark E. Douglas, JD, MSN, RN 19 King County Care Partners: a community based chronic care management system for Medicaidclients with co-occurring medical, mental, and substance abuse disorders 339 Daniel S. Lessler, MD, MHA, Antoinette Krupski, PhD, and Meg Cristofalo, MSW, MPA 20 Predictive Risk Intelligence SysteM (PRISM): a decision-support tool for coordinating care forcomplex Medicaid clients 349 Beverly J. Court, MHA, PhD, David Mancuso, PhD, Chad Zhu, MS, and Antoinette Krupski, PhD 21 High-risk patients in a complex health system: coordinating and managing care 361 Maria C. Raven, MD, MPH, MSc 22 The SoonerCare Health Management Program 371 Carolyn J. Reconnu, RN, BSN, CCM, and Mike Herndon, DO Section 5 Practice Change 23 Introduction: practice change fellows initiatives 379 Eric A. Coleman, MD, MPH, and Nancy Whitelaw, PhD 24 Interdisciplinary care of chronically ill adults: communities of care for people living with congestiveheart failure in the rural setting 383 Lee Greer, MD, MBA 25 Collaborative care treatment of late-life depression: development of a depression support service391 Eran D. Metzger, MD 26 Geriatric Telemedicine: supporting interdisciplinary care 407 Daniel A. Reece, MSW, LCSW 27 Integrated Patient-Centered Care: the I-PiCC pilot 417 Karyn Rizzo, RN, CHPN, GCNS Section 6 Medicare Managed Care 28 Longitudinal care management: High risk care management 431 Chandra L. Torgerson, RN, BSN, MS, and Lynda Hedstrom, MSN, APRN, NP-C Section 7 International Care Coordination 29 The experiences in the Republic of Korea 441 Weon-seob Yoo, PhD, MPH, MD, and Joo-bong Park Oh, MN, MS, PsyD, RN Index 451
Cheryl Schraeder, RN, Ph.D., FAAN is currently Clinical Associate Professor and also Director of Policy and Practice Initiatives, Institute for Healthcare Innovation, at the College of Nursing at the University of Illinois in Chicago, IL. Dr. Schraeder has been the project director/ principle investigator for governmental health care agencies and private foundation demonstrations and projects with vulnerable populations. Paul S. Shelton, EdD is currently Senior Research Specialist at the Institute for Healthcare Innovation at the College of Nursing at the University of Illinois in Chicago, IL. Dr. Shelton has extensive experience in working with governmental health care agencies and private foundations in primary care management demonstrations.
