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…mehr
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.
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.
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PART 1 THEORETICAL CONCEPTS 1 Chronic illness Paul Shelton EdD Cheryl Schraeder RN PhD FAAN Michael K. Berkes BS MSW Candidate and Benjamin Ronk BA 2 Overview 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 Randall S. Brown PhD Arkadipta Ghosh PhD Cheryl Schraeder RN PhD FAAN and Paul Shelton EdD 4 Promising practices in integrated care Patricia J. Volland MSW MBA and Mary E. Wright 5 Intervention components 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 Robert Newcomer PhD and L. Gail Dobell PhD 7 Health information technology David A. Dorr MD MS and Molly M. King BA 8 Financing and payment Julianne R. Howell PhD Robert Berenson MD and Patricia J. Volland MSW MBA 9 Education of the interdisciplinary team 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 Chad Boult MD MPH MBA Carol Groves RN MPA and Tracy Novak MHS 11 Care management plus Cherie P. Brunker MD David A. Dorr MD MS and Adam B. Wilcox PhD 12 Medicare coordinated care 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 Susan Rosenbek RN MS and Eric A. Coleman MD MPH 14 Enhanced Discharge Planning Program at Rush University Medical Center 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 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) Brenda Sulick PhD and Christine van Reenen PhD \ SECTION 4 MEDICAID MODELS 17 Introduction to Medicaid care management Allison Hamblin MSPH and Stephen A. Somers PhD 18 The Aetna Integrated Care Management Model: a managed Medicaid paradigm 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 Medicaid clients with co-occurring medical mental and substance abuse disorders 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 for complex Medicaid clients 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 Carolyn J. Reconnu RN BSN CCM and Mike Herndon DO SECTION 5 PRACTICE CHANGE 23 Introduction: practice change fellows initiatives Eric A. Coleman MD MPH and Nancy Whitelaw PhD 24 Interdisciplinary care of chronically ill adults: communities of care for people living with congestive heart failure in the rural setting Lee Greer MD MBA 25 Collaborative care treatment of late-life depression: development of a depression support service Eran D. Metzger MD 26 Geriatric Telemedicine: supporting interdisciplinary care Daniel A. Reece MSW LCSW 27 Integrated Patient-Centered Care: the I-PiCC pilot Karyn Rizzo RN CHPN GCNS SECTION 6 MEDICARE MANAGED CARE 28 Longitudinal care management: High risk care management 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 Weon-seob Yoo PhD MPH MD and Joo-bong Park Oh MN MS PsyD RN
PART 1 THEORETICAL CONCEPTS 1 Chronic illness Paul Shelton EdD Cheryl Schraeder RN PhD FAAN Michael K. Berkes BS MSW Candidate and Benjamin Ronk BA 2 Overview 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 Randall S. Brown PhD Arkadipta Ghosh PhD Cheryl Schraeder RN PhD FAAN and Paul Shelton EdD 4 Promising practices in integrated care Patricia J. Volland MSW MBA and Mary E. Wright 5 Intervention components 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 Robert Newcomer PhD and L. Gail Dobell PhD 7 Health information technology David A. Dorr MD MS and Molly M. King BA 8 Financing and payment Julianne R. Howell PhD Robert Berenson MD and Patricia J. Volland MSW MBA 9 Education of the interdisciplinary team 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 Chad Boult MD MPH MBA Carol Groves RN MPA and Tracy Novak MHS 11 Care management plus Cherie P. Brunker MD David A. Dorr MD MS and Adam B. Wilcox PhD 12 Medicare coordinated care 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 Susan Rosenbek RN MS and Eric A. Coleman MD MPH 14 Enhanced Discharge Planning Program at Rush University Medical Center 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 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) Brenda Sulick PhD and Christine van Reenen PhD \ SECTION 4 MEDICAID MODELS 17 Introduction to Medicaid care management Allison Hamblin MSPH and Stephen A. Somers PhD 18 The Aetna Integrated Care Management Model: a managed Medicaid paradigm 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 Medicaid clients with co-occurring medical mental and substance abuse disorders 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 for complex Medicaid clients 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 Carolyn J. Reconnu RN BSN CCM and Mike Herndon DO SECTION 5 PRACTICE CHANGE 23 Introduction: practice change fellows initiatives Eric A. Coleman MD MPH and Nancy Whitelaw PhD 24 Interdisciplinary care of chronically ill adults: communities of care for people living with congestive heart failure in the rural setting Lee Greer MD MBA 25 Collaborative care treatment of late-life depression: development of a depression support service Eran D. Metzger MD 26 Geriatric Telemedicine: supporting interdisciplinary care Daniel A. Reece MSW LCSW 27 Integrated Patient-Centered Care: the I-PiCC pilot Karyn Rizzo RN CHPN GCNS SECTION 6 MEDICARE MANAGED CARE 28 Longitudinal care management: High risk care management 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 Weon-seob Yoo PhD MPH MD and Joo-bong Park Oh MN MS PsyD RN
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