Main description:

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.

Contents:

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