55–64 years 11 65–74 years 7 75–84 years 5 85+ years 1 Female 55 55–64 years 52 65–74 years 56 75–84 years 59 85+ years 66 Minority race 20 Not Married 48 Education Less than high school 17 College degree (bachelor’s or above) 26 Household income below poverty level 9 Health insurance coverage 55–64 years 88 Employer/private 68 Disabled 10 Medicaid 7 65+ years Medicare 93 Medicare and Medicaid 10 Medigap 59 Military-based 7 Health rated fair/poor 23 Chronic Illnesses 55–64 years 1 chronic condition 20 2+ chronic conditions 57 65+ years 1 chronic condition 15 2+ chronic conditions 77 Hypertension 55 Heart disease 25 Diabetes 16 Hearing problems 32 Vision problems 14 Obesity 23 Any difficulty with physical activities 25 Any difficulty with social activities 10 Health Behaviors Leisure-time physical activity 52 Current smoker 23 Prior healthcare use Regular source of care 94 Any ER visit 22 Any hospital admission 55 to 64 years 13 65+ years 33

A profile of older adults aged 65 years of age and older

The increasing number of Americans 65 years of age and older, coupled with their complex health needs, is one of the leading causes of escalating costs of health care. The 65-and-over age group has grown twice as fast as the rest of the U.S. population in the past 20 years. One out of eight Americans is now 65 or older (AoA 2009). These growing numbers of older Americans, especially those 75 years of age and over, will present the greatest challenge from economic and human service perspectives because age 75 appears to be the point in the lifespan when disability, morbidity, and mortality rates begin to rapidly increase.

The Medicare program enables older Americans to obtain health care services. However, in its current form, Medicare lacks many of the essential components of a high-quality, efficient health system (Medicare Payment Advisory Commission [MedPAC] 2010a). Program spending and utilization have increased substantially over the last three decades, primarily because for Medicare beneficiaries chronic illness is the norm rather than the exception (Wolff & Boult 2005). It is estimated that if current spending and utilization trends continue, the long-term viability and sustainability of Medicare is in jeopardy (MedPAC 2010a).

Despite the increased prevalence of chronic illness, generalizations about health concerning the elderly are difficult because they are not a homogeneous group. Many people remain relatively healthy and vigorous into their 70s and beyond, while others develop serious illnesses and functional impairment in their 50s and 60s. Chronic illnesses are associated with varying levels of severity (Anderson 2010). Some chronic illnesses are extremely debilitating and others produce effects that are hardly noticeable on an individual’s health. Some chronic illnesses are not disabling when diagnosed, but may lead to poorer health later on in life if not treated early and effectively. Some people with chronic illnesses live full, productive lives even with limitations; others experience depression, isolation, and a reduced quality of life.

In this section, we present a summary of demographic and health-related characteristics of adults 65 years of age and older and also specific characteristics of Medicare beneficiaries. The principal sources of data for this section are from the U.S. Bureau of the Census, the NCHS, the Bureau of Labor Statistics, and the Centers for Medicare & Medicaid Services (CMS) Medicare Current Beneficiary Survey. All summary statistics are based on the latest published data available. Selected characteristics are summarized in Table 1.2.

Demographics

Adults 65 years and older represented 13% of the total population in 2008, and are estimated to be over 19% by 2030 (AoA 2009). Females outnumbered males at a 1.36 to 1.0 ratio (136 women for every 100 men). Minorities comprised 19% of the population but are projected to account for 38% of the population by 2050 (Federal Interagency Forum on Aging-Related Statistics 2008). Older men were more likely to be married than older women (72% versus 42%), and widowhood was more common among older women than men (AoA 2009). Marital status had a direct relationship with living arrangements; 19% of older men lived alone compared to 39% of older women. Approximately 78% of both women and men were high school graduates, and about 20% were college graduates. Older men had higher rates of college graduation than women (25% versus 20%; AoA 2009; Federal Interagency Forum on Aging-Related Statistics 2008). Median household income was $44,000 and 10% had incomes below the poverty level (AoA 2009). A greater percentage of minorities lived in poverty than Caucasians. These low-income elderly represent a diverse and complex group that frequently has socioeconomic stressors, limited or low health literacy, and limited access to health care (Counsel et al. 2007).

About half of the total population of individuals aged 65 or older (51%) lived in nine states: California, Florida, New York, Texas, Pennsylvania, Illinois, Ohio, Michigan, and New Jersey. In 11 states they comprised 14% or more of the state population: Florida (17%); West Virginia (16%); Pennsylvania, Maine, Iowa, Hawaii, and North Dakota (each 15%); South Dakota and Arkansas (each 14%), and Rhode Island (14%).

Health status

Only 39% of adults 65 and older rated their current health as excellent or very good (AoA 2009). Racial minorities were less likely to rate their health as excellent or very good compared to Caucasians. Over 50% of adults had at least one chronic illness and many had multiple illnesses. The most frequently occurring chronic illnesses were hypertension (53%), arthritis (46%), heart disease (30%), COPD (22%), any cancer (21%), diabetes (18%), and stroke (9%; Federal Interagency Forum on Aging-Related Statistics 2008). Women reported higher rates of arthritis than men (54% versus 43%); men reported higher levels of heart disease (37% versus 26%) and cancer (24% versus 19%) than women. African Americans reported higher levels of hypertension and diabetes than other racial groups. Almost half of men (48%) and approximately one-third of women (35%) reported trouble hearing. Vision trouble affected about 17% of both men and women. Older adults who lived in poverty consistently had higher rates of kidney disease, CHF, heart disease, mental illness, and diabetes, compared to middle or upper-income older adults (AHRQ 2006).

Some form of disability (difficulty with memory, walking, self-care, or independent living) was reported by 38% of older adults, and 16% needed some type of assistance as a result (AoA 2009). There was a strong correlation between disability status and health status. Among those with a severe disability, 64% were in fair or poor health. Based on 2005 data, 42% had at least one ADL or IADL limitation, and women had higher levels of functional limitations than men (Federal Interagency Forum on Aging-Related Statistics 2008).

Health habits

The percentage of older adults who engaged in regular leisure-time physical activity is somewhat small; only about 26% of adults aged 65 to 74 engaged in regular physical activity, and only 19% of persons 75 years of age or older did so (AoA 2009). Based on height and weight combinations 31% were obese; there were no significant differences in obesity based on gender. Only about 9% were still smokers. Poverty was associated with higher levels of inactivity and cigarette smoking but not obesity (NCHS 2010).

Health service utilization

Almost one in every four adults 65 years of age or older had an ER encounter at least once in the previous year (23%) and 9% had two or more visits (NCHS 2010). Poverty and Medicaid coverage increased the likelihood of ER usage. It has been estimated that ER visit rates will steadily increase among the elderly in coming decades (Wilber et al. 2006) which will place more strain on health care resources. The emergency care of older adults is often time and resource intensive, and complicated by underlying chronic illnesses. This increase in future utilization is especially noteworthy since about 33% of elderly patients discharged from the ER are prone to experience an adverse event within 90 days of the index visit, returning to the ER for another visit with or without a hospital admission, nursing home admission, or death (Hastings et al. 2008).

About 33% of adults were hospitalized at least once during the past 12 months (Levit et al. 2009), and 6% experienced two or more hospital admissions during the same time period (NCHS 2010). Rehospitalization rates among Medicare beneficiaries are high. In 2004, almost one fifth (19.6%) of beneficiaries who had been discharged from a hospital were rehospitalized within 30 days, and 34% were rehospitalized within 90 days; 67% of patients who had been discharged with medical conditions and 52% with surgical procedures were rehospitalized or died within 12 months after discharge (Jenks et al. 2009). Among patients rehospitalized within 30 days after a surgical procedure, about 70% were rehospitalized with a medical condition. The most frequent medical reasons for rehospitalization included CHF, pneumonia, COPD, psychoses, and GI problems. The most frequent surgical reasons for rehospitalization included cardiac stent replacement, major hip/knee surgery, other vascular surgery, major bowel surgery, and other hip or femur surgery.

In 2006, the median annual health care cost for these adults was approximately $4,000 per person; about 25% had no expenses or expenses under $1,750; and 25% had expenses over $9,300 (Machlin 2009). Over 50% of individual out-of-pocket spending, excluding health care coverage, was for prescription medications (NCHS 2010). Viewed from another perspective, in 2002 the elderly accounted for 36% of all health care expenses (Cohen & Yu 2006).

Medicare beneficiaries

The Medicare program provides health insurance coverage to Americans who are age 65 or older, under age 65 with certain disabilities, and individuals of all ages diagnosed with End-Stage Renal Disease (ESRD). Medicare Part A, the Hospital Insurance Program, assists in the coverage of inpatient hospital care, inpatient care in a skilled nursing facility, hospice services, and some home health care services. Beneficiaries are automatically enrolled and do not pay a monthly premium for Part A. Medicare Part B, the Medical Insurance Program, helps pay for physician services, outpatient care, some preventive services, and some services not covered under Part A, such as home health care and physical and occupational therapy. Beneficiaries are automatically enrolled unless they opt out, and they must pay a monthly premium for Part B that is deducted from their monthly Social Security benefits. Medicare Part D is a prescription drug benefit provided by private insurance companies. Part D may help lower prescription drug costs for some beneficiaries, and premiums must be paid for by the beneficiary. Below we present a snapshot of the Medicare fee-for-service (FFS) population, with an emphasis on health care utilization and expenditures.

Table 1.2 Selected Characteristics of the Medicare Population

Sources: CMS 2002; Federal Interagency Forum on Aging-Related Statistics 2008; NCHS 2010; MedPAC 2010b.

The Medicare population in 2006 was composed of the elderly (84%), the disabled (16%), and individuals with ESRD (less than 1%; MedPAC 2010b). The typical Medicare beneficiary was a Caucasian female (56%) between 65 and 74 years of age (42%), who lived with her spouse (49%), attended some college or was a college graduate (41%), and rated her health as good or fair (51%). Most beneficiaries lived in urban areas (76%), had annual household incomes between $15,000 and $25,000 (22%; CMS 2002), and had some form of supplemental insurance coverage (90%). Their chronic illnesses were arthritis (55%) and hypertension (55%), and they had no ADL or IADL limitations (CMS 2002). Medicare spent an average of $8,865 in 2006 for their health care services (MedPAC 2010b). For more characteristics of the Medicare population see Table 1.2.

Dual-eligible beneficiaries, those who qualify for both Medicare and Medicaid, accounted for 16% of the total Medicare population in 2006 (MedPAC 2010b). They were eligible for Medicaid because of low household income: 51% lived below the poverty level. They were more likely to be female, African American or Hispanic American; they lacked a high school education, had more ADL and/or IADL limitations, lived in rural areas, and lived either in an institution, alone, or with persons other than a spouse. They were more likely to be under 65 years of age (41%), have higher rates of poor health (20%), diabetes, COPD, stroke, and Alzheimer’s disease compared to non-dual-eligibles. They accounted for 27% of total Medicare expenditures and averaged per capita expenses of $15,384, which is more than twice that for non-dual-eligible beneficiaries.

In 2008, health care spending was approximately $1.95 trillion (MedPAC 2010b), and accounted for 16% of the gross domestic product (Stanton & Rutherford 2006). Medicare is the largest single purchaser of health care in the United States, and accounted for 23% of total spending in 2006 (MedPAC 2010b). The rest of health care spending came from private insurance payers (35%) and from out-of-pocket spending. All public programs, including Medicare, Medicaid, the State Children’s Health Insurance Program, and other programs, accounted for 47% of total spending.

Medicare spending presents a more complex picture than beneficiary demographics and their health status. In 2008 Medicare accounted for 29% of all national spending on hospital care, 21% of physician and clinical services, 41% of home care services, 19% of nursing home care, 30% of durable medical equipment, and 22% of prescription drugs (MedPAC 2010b). According to 2009 data, inpatient hospital services accounted for 27% of Medicare expenditures, 13% for physician services, and 12% for prescription drugs under Part D. Total Medicare expenditures in any given calendar year are spent among a very small number of beneficiaries. In 2006, the costliest 5% of beneficiaries accounted for 39% of total Medicare spending. In contrast, 50% of beneficiaries accounted for only 4% of total program expenses. The costliest beneficiaries tended to be the chronically ill, who experienced multiple hospital admissions, were covered by both Medicare and Medicaid (dual-eligibles), and were within in the last year of their lives.

The burden of chronic illness

Over half of Americans suffer from at least one chronic illness. Despite tremendous advances in treatment, chronic illness rates have risen dramatically. Diabetes has become a “new” national epidemic, and escalating rates of obesity and cardiovascular disease threaten to derail previous advances made in reducing these disease rates (DeVol & Bedroussian 2007). It has been estimated that without significant change in chronic illness care and lifestyle, the incidence of cancer, mental disorders, and diabetes will increase by 50% in the next two decades, and heart disease will increase by more than 40% (Partnership to Fight Chronic Disease 2009).

Chronic illnesses are having an enormous impact on human and economic aspects of society. It has been suggested that the health of Americans and the economy depend on our ability to focus efforts on reducing the burden of chronic illness, because if not, the socioeconomic consequences will be staggering and could negatively impact the lifestyles of all Americans (DeVol & Bedroussian 2007). In this section we present a snapshot of the burdens caused by chronic illnesses.

Chronic illness prevalence

Today, 50% of Americans suffer from at least one chronic illness (Partnership to Fight Chronic Disease 2009), and four out of five older adults, aged 50 and older, suffer from at least one chronic illness (AARP 2009a). This prevalence differs by race: 77% of African Americans have at least one chronic illness, as do 68% of Hispanic Americans; 64% of Caucasians; and 42% of Asian Americans (Collins et al. 2002). A quarter of Americans (28%) have multiple chronic illnesses (Anderson 2010).

Additionally, some chronic illnesses are associated with higher risk of co-morbidity than others. For example, people with CHF, kidney disease, or stroke are more likely to have five or more other chronic illnesses than people with arthritis, mental disorders, or cancer (AARP 2009a). Similarly, the relationship of select chronic illness and co-morbidity-risk are associated with age and gender. Using an algorithm developed by Weiss and colleagues (2007), it is possible to estimate major chronic illness co-occurrence in older adults. For example, following their formula, approximately 14% of elderly women with chronic lower respiratory tract illness (emphysema, chronic bronchitis, or asthma) will also have both diabetes and severe arthritis compared to 20% of elderly men. However, few researchers have studied the clustering of chronic illnesses, which has a direct impact on how care is provided to these individuals and ultimately on clinical outcomes (Vogeli et al. 2007).

Chronic illnesses’ impacts on health service use

Individuals with chronic illnesses, typically adults 55 years of age or older and those with multiple chronic illnesses, are the heaviest users of health care services. They are the highest users in all major health service areas including hospitalizations, physician visits, home health care, and prescription medications (Anderson 2010). They account for a majority of annual health care expenditures. Based on recent 2006 data, individuals with one or more chronic illnesses accounted for: 79% of physician visits, 97% of home health visits, 79% of hospital admissions, and 93% of individuals filling prescription medications (Anderson 2010).

Both home health care and physician visits have increased significantly alongside the number of chronic illnesses (Anderson 2010). Physician visits increased from an annual average of three visits for one chronic illness, to twelve visits for someone with five or more chronic illnesses (or four times as many annual visits). Home health visits showed a similar trajectory; visits for one chronic illness averaged one annual visit versus eleven visits for someone with five or more chronic illnesses. Additionally, the same pattern of chronic illnesses, combined with ADL or IADL limitations, impacted these visits. Physician visits increased from five annual visits for an individual with one chronic illness and any ADL/IADL limitation compared to fourteen visits for someone with five or more chronic illnesses, or three times as many annual visits. Individuals with one chronic illness and any ADL/IADL averaged six annual home health visits compared to seventeen for someone with five or more chronic illnesses.

A different pattern emerged when physician visits for elderly adults were examined, regarding those 65 years of age or older and covered by Medicare. The burden placed on health care providers was magnified radically (Berenson 2007). Medicare beneficiaries with one chronic illness averaged 8 annual visits with 4 different physicians. These numbers increased noticeably based on the number of chronic illnesses. Medicare beneficiaries with two chronic illnesses averaged 11 visits with 5 different physicians; beneficiaries with three chronic illnesses averaged 15 visits with 7 different physicians; beneficiaries with four chronic illnesses averaged 20 visits with 8 different physicians; and beneficiaries with five or more chronic illnesses averaged 37 visits with 14 different physicians.

Individuals with chronic illness were more likely to be hospitalized (Anderson 2010). About 4% of individuals with no chronic illnesses were hospitalized in a 12-month period; however, the incidence increased to 6% with one chronic illness, 10% for two, 14% for three, 19% for four, and 27% for five or more. A similar pattern emerged when comparing any ADL/IADLs limitation with the number of chronic illnesses. Individuals with a chronic illness and any ADL/IADL limitation had a hospitalization rate of 13%, and increased to 17% for two chronic illnesses, 23% for three chronic illnesses, 26% for four chronic illnesses, and 31% for five or more chronic illnesses.

Individuals with chronic illnesses accounted for the majority of prescription medications (Anderson 2010). On average, individuals with one chronic condition filled 7 prescriptions annually, which increased to 16 prescriptions for two chronic illnesses, 27 for three chronic illnesses, 36 for four chronic illnesses and 57 for five or more. This same pattern was visible when comparing the likelihood of filled prescription medications and number of chronic illnesses. Approximately 13% of individuals with one chronic illness and any ADL/IADL limitation filled a prescription in a 12-month period compared to 22% for individuals with two chronic illnesses, 35% for individuals with three chronic illnesses, 42% for individuals with four chronic illnesses, and 65% for individuals with five or more chronic illnesses.

Chronic illness impact on health care costs

In 2006, 50% of individuals diagnosed with one or more chronic illness accounted for 84% of all health care spending (Anderson 2010). These expenditures were disproportional compared to the percentage of individuals with no chronic illnesses and their insurance coverage: 78% of private health-insurance spending was on the 48% of individuals with chronic illnesses; 79% of Medicaid spending was on the 40% of non-institutional individuals with chronic illnesses; and 98% of Medicare spending was on beneficiaries with chronic illnesses. The number of chronic illnesses accelerated health care spending. Compared to individuals with no chronic illnesses, annual expenditures are almost three times greater for someone with one chronic illness, over seven times greater for someone with three chronic illnesses, and almost 15 times greater for someone with five or more chronic illnesses (Anderson 2010). There was also a significant difference in health care spending on chronically ill individuals with ADL or IADL limitations. Individuals with one or more ADL/IADL limitations and five or more chronic illnesses had average annual health expenditures that were more than double compared to individuals with one or more ADL/IADL limitations and only one chronic illness (approximately $17,000 versus $6,000).

Ultimately, how much a particular chronic illness contributes to health care spending is a product of the total cost of treatment and the impact the disease has on life expectancy (AARP 2009a). For example, a 65-year-old adult with a serious chronic illness will cost Medicare an additional $1,000 to $2,000 per year until death, compared to a similar aged adult without the condition (Joyce et al. 2005). Over an adult’s remaining life expectancy from age 65, diabetes is estimated to be more costly than cancer ($15,000 in additional spending versus $13,500), and hypertension more costly than stroke ($11,000 versus $4,000), despite differences in shorter life expectancy associated with the chronic illnesses. Lifetime Medicare spending on elderly individuals who are obese is estimated to be $25,000 to $37,000 more compared to beneficiaries of normal weight (Thorpe & Ogden 2010). From age 70 until death, Medicare spends approximately 35% more on obese beneficiaries compared to those of normal weight, primarily because of higher co-morbidity among very old obese beneficiaries (Yang & Hall 2008).

Although inpatient care is the largest category of Medicare expenditures, in recent years the prevalence and changing mix of treatment locations for chronic illnesses have had noticeable effects on the rise in Medicare spending (Thorpe et al. 2010; Decker et al. 2009). Increases in the rates of diabetes, kidney disease, hypertension, hyperlipidemia, mental disorders, and arthritis among Medicare beneficiaries have reduced spending growth for inpatient hospital services. At the same time, because these illnesses are primarily treated in the outpatient setting and at home by prescription drugs, the growth of Medicare spending has largely been attributable to increases in physician visits, prescription medications, and home health care services.

Chronic illness impact on patient care and caregivers

An older America, coupled with advances in medical technology and treatment, has resulted in a substantial reported increase in chronic illnesses. We have seen that this phenomenon has resulted in significantly higher health care utilization and spending, but how have these trends impacted chronically ill adults, their families, and caregivers? Two surveys have highlighted that unfortunately, these individuals and their caregivers have often experienced shortcomings in chronic illness care that they have received (Harris Interactive 2001; AARP 2009b). These surveys found that chronically ill adults experienced numerous quality of care problems, including issues with timely access to care when sick, a lack of care coordination and adequate information, major medical errors, unnecessary medical tests, potentially unnecessary hospital readmissions, and inadequate follow-up care after hospital discharge.

Ongoing challenges for chronically ill adults in receiving care included not being able to see a physician when they felt it was necessary, concerns that their insurance did not cover all types of care needed, and that the costs of care were a financial burden (Harris Interactive 2001; AARP 2009b). Chronically ill adults with three or more chronic illnesses experienced consistently high out-of-pocket expenses compared to those with no chronic illnesses, especially the near elderly (Cunningham 2009; Paez et al. 2009). Chronically ill adults also experienced different diagnoses for the same symptoms from different physicians, and some were warned by a pharmacist about a potentially harmful interaction between medications prescribed for them by one or more of their physicians.

Table 1.3 A Synopsis of Chronic Illness

Poor communication patterns were prominent among providers and chronically ill adults and their caregivers (AARP 2009b). Common problems included that the provider did not have all the needed information when the patient arrived for the visit, the patient and/or caregiver did not understand what they had been told by the provider, and they were not told the purpose of or how to take a newly prescribed medication.

Chronically ill adults were reluctant to ask for help, and few of them ever asked for assistance from outside the immediate family (Harris Interactive 2001). On average, family caregivers had provided care for a loved one for about four and a half years. When these caregivers needed help, they more often sought assistance from local religious and/or community organizations they were familiar with. Like the chronically ill adult they cared for, caregivers were not likely to ask for assistance, even from other relatives or close friends.

Family caregivers are a critical support structure for individuals with chronic illnesses. In any given year, over 50 million Americans find themselves in a caregiving role (Partnership to Fight Chronic Disease 2008). Almost one in five (17%) family caregivers provide 40 hours of care a week or more, and provide a majority (80%) of all long-term care services for those with a chronic illness or disability. Family caregivers who experience extreme stress while caring for their loved one with chronic illness or disability have been shown to be more prone to chronic diseases themselves and they age prematurely. Children of aging parents are twice as likely as non-caregivers to suffer from depression, and spouses are six times as likely to suffer from depression (Partnership to Fight Chronic Disease 2008). Caregiving families tend to have incomes that are $15,000 less than non-caregiving families, yet they spend 2.5 times more on out-of-pocket expenses.

Summary

As Americans have become increasingly older, so have the number living with chronic illnesses. Our current health care system was not designed to provide coordinated care for these individuals who are primarily insured by the Medicare and Medicaid programs. As a result, these individuals are not receiving optimum quality of care for many of their chronic illnesses. As the “baby boom generation” gets ready to become Medicare beneficiaries, more providers with specialized training, resources, and new approaches to delivering care for chronic illnesses will be needed to meet their health care needs.

Improving care for the chronically ill is one of the most important challenges facing our health care system. Research has consistently demonstrated that maintaining and sustaining improvements in care management and coordination for chronically ill adults is extremely difficult. Additionally, dysfunctional incentives have contributed to a fragmented system that has failed to address the fundamental causes of chronic illness, and too many care decisions have been removed from the control of clinicians and patients.

The prevalence of chronic illness is steadily increasing, and by 2030 it is estimated that the number of adults with at least one chronic illness will be in excess of 171 million. Besides longevity, lack of physical activity, tobacco use, and poor nutrition habits are directly responsible for increased rates of chronic illnesses, including cancer, COPD, diabetes, and heart disease. The chronically ill have significantly higher rates of disability, mortality, health care utilization, and medical expenses compared to people without chronic illnesses.

Rates of chronic illness are correlated with socioeconomic status and ethnicity. Adults who live near or below the poverty level and are racial minorities experience significantly higher levels of chronic illnesses and disability. Projections indicate that these incidences will only get worse in the future.

The data indicate that the current care provided to chronically ill adults and their caregivers often leads to poor outcomes. In clinical practice, chronic illness management typically falls short of effective communication and coordination across different care settings and providers. As a result, patients and their families/caregivers experience the brunt of the chronic illness burden.

It has been acknowledged and acclaimed by medical experts and policy makers that our health care system is dysfunctional and for all purposes, broken. Almost all agree that changes are necessary, especially when it comes to financing and delivering medical care for individuals with chronic illnesses. In the proceeding chapters we present information that addresses the current state of chronic illness care, and we offer evidence-based suggestions that have the potential to positively impact care management and address the issues of fragmentation and care coordination for the chronically ill.

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