Chapter 2

Overview

Cheryl Schraeder, Paul Shelton, Linda Fahey, Krista L. Jones, and Carrie Berger

Introduction

Asa result of scientific advances and public health initiatives implemented over the past century, American longevity has increased by three decades (Centers for Disease Control [CDC] 2007). Along with this increased longevity, there has been a steady increase in the number of individuals living with one or more chronic illnesses. In the coming decade the number of Americans afflicted by chronic disease is expected to reach 150 million (CDC 2007).

Chronicillness profoundly affects a person’s physical, emotional, and mental health status, often making it difficult for them to complete simple tasks or carry on with daily routines, thereby negatively impacting their overall quality of life. These challenges are compounded by an increasingly complex and fragmented health care system in which chronic illness patients receive care from multiple providers who are often unaware of the diagnoses and treatment provided by their colleagues in managing the patients’ chronic diseases.

Uncoordinated care results in polypharmacy issues, conflicting advice, contraindication in care regimens, increased medical errors, waste of health services and resources, and ineffective provider billing and reimbursement (Bodenheimer 2008; Pham et al. 2007). This chapter will explore the need for comprehensive care coordination, review barriers impacting implementation, and discuss facilitators toward adherence to this strategy.

Comprehensive care coordination defined

Overall, it is obvious that our health care system has failed to embrace and provide comprehensive care coordination. However, a new level of energy was created when the Patient Protection and Affordable Care Act (PPACA) was signed into law in 2010. In this legislation, referred to as federal health care reform, the concept of coordinated care was mentioned 25 times. Unfortunately, a formal definition of coordinated care was not included in the law. An inability to define the process and assert meaning to the benefits derived from the coordinated delivery of services to patients, their families and caregivers, combined with the basic structure and focus of the current health care system, will more than likely impact its future adoption.

Our approach to comprehensive care coordination is shaped by the definition of care management employed by Bodenheimer and Berry-Millett (2009a) and Bodenheimer and colleagues (2009b). For our purposes, care coordination is a set of activities that assist patients and their families in self-managing their health conditions and related psychosocial problems more effectively; coordinating their care among multiple health and community providers; bridging gaps in care; and receiving the appropriate levels of care. Care coordination is generally provided by a registered nurse (RN) in collaboration with the patient/family, their primary care provider, and other health and community providers involved in the patient’s health care. RN care coordinators maintain a panel of patients over time and primarily see patients face-to-face in the home, in a clinical office setting, or they contact patients by telephone.

The specific activities of care coordination include: (1) assessing the risks and needs of each patient, including knowledge of their health conditions, current level of self-management activities, and their own goals of care; (2) developing a comprehensive care plan that is based upon evidenced-based guidelines and standards of care; (3) ensuring that patients are up-to-date on current recommended health promotion activities; (4) teaching and coaching patients and their families about their health conditions and medications, including self-management activities and how to anticipate and plan for their needs based upon their prior responses to their health conditions and contact with the health care system; (5) empowering and supporting patients to take ownership of their health conditions and management options; (6) coaching and guiding patients and families on how to respond to worsening symptoms in order to avoid emergency department (ED) visits and hospital admissions; (7) proactive patient monitoring to identify changes in their health status or related psychosocial needs; (8) communicating pertinent information to involved providers during care transitions; (9) tracking patients’ health status over time with early communication to other providers of any change or psychosocial needs; (10) evaluating the effectiveness of the plan of care, and teaching patients to evaluate self-management activities; and (11) revising care plans to reflect changes in a patient’s health status, psychosocial needs, and self-management skills.

Rose is a 78-year-old woman who was diagnosed with type 2 diabetes 10 years ago. She also has a history of incontinence, arthritis, and depression – the latter developing because of the loss of her husband after 55 years of marriage. Five years ago, Rose was diagnosed with hypertension following an episode of acute myocardial infarction (AMI). While hospitalized for the AMI, Rose was placed on a higher dosage and schedule of insulin. As a result, Rose suffered hypoglycemia, further complicating her cardiac condition and prolonging her hospital stay.

Rose sees a primary care physician, urologist, cardiologist, endocrinologist, certified diabetes educator, and psychiatrist. Rose’s daughter and grandchildren provide most of her care including taking her to provider appointments. As a result of her co-morbidities and a lack of comprehensive care coordination, she has been the victim of conflicting medical advice and polypharmacy.

Rose’s story is one of thousands that exemplify a need for chronic care coordination. In the next section, we address the barriers encountered by care coordinators and patients like Rose when seeking to assure comprehensive service delivery.

Barriers to comprehensive care coordination

Fragmentation

Accessibility and the affordability of patient care are hindered by a complex, fragmented, and overwhelmed system of care. Imagine a time when you had an illness and sought treatment from a primary care provider. Most likely you called to make an appointment with the receptionist or scheduling center. From that point you may have been directed to the Billing Department to assure that you had coverage to pay for the appointment. Upon seeing the primary care provider, you were informed that you required further testing and diagnosis with a specialist. You began the cycle again for the next level of appointments. Imagine you have multiple chronic illnesses, scheduling multiple appointments for diagnosis, treatment, and follow-up care, all the while assuring your providers that your appointments, medications, therapy, and all other forms of treatment are covered by your health insurance.

Approximately 20% of adults have a chronic disability (U.S. Census Bureau 2010). The care of these patients is currently being managed within a fragmented system of multiple specialists and primary care providers at multiple settings, including ambulatory care clinics, private physician offices, the ED diagnostic services (radiology/lab), and hospitals. This fragmentation leads to poor communication across providers and settings, duplication of services, excess utilization of acute care services (particularly the ED), polypharmacy, higher costs, higher rates of non-compliance with treatment, and poorer patient outcomes (Luck et al. 2007).

Kroll and colleagues (2006) identified multiple barriers affecting access to primary preventative services for individuals with a chronic disability. They divided these barriers into two primary domains: structural-environmental (conditions in the physical and social environment impacting service delivery), and process (barriers experienced as services were provided to patients).

Examples of structural-environmental barriers include: lack of transportation services to appointments, lack of disabled parking spaces and wheelchair ramps into medical buildings, lack of adaptable equipment such as accessible bathrooms, special weight scales for individuals in wheelchairs, and adjustable exam tables. Many providers are ill-equipped to meet the needs of this disadvantaged population, often citing structural concerns and the need for re-design of medical facilities.

Examples of process barriers include poor communication among providers, failure to receive preventative teaching, and lack of consistent health promotion strategies (Kroll et al. 2006). Additionally, patients often experience a lack of flexibility in scheduling appointments, long telephone waits, automated answering systems, failure of providers to return calls in a timely manner, and feeling rushed during provider visits, resulting in an inability to have questions addressed (Coughlin et al. 2002).

Bayliss and colleagues (2008; 2003) described challenges faced by elderly patients with multiple chronic illnesses, including access to their primary provider, difficulty scheduling appointments, “telephone tag” with provider offices, lack of e-mail communication, and the frustrations of traveling long distances to see multiple specialists. In addition, patients expressed concerns about physician turnover in large practices and the difficulty with repeating their history over and over to new incoming providers. Limited coordination of care, lack of a cohesive plan to manage their multiple conditions, and an inability on the part of providers to give patients time to have their concerns addressed during appointments, as well as be an active participant in the plan of care, were additional barriers to effective care management.

Adults with multiple chronic illnesses echoed similar barriers. Jerant and colleagues (2005) identified barriers these individuals face to active self-management and in accessing self-management support services. Barriers to active self-management included depression, weight problems, difficulty exercising, fatigue, poor physician communication, low family support, pain, and financial problems. Lack of awareness, physical symptoms, transportation issues, and cost/lack of insurance coverage were barriers to accessing self-management support.

When barriers are faced with the physician office, patients often turn to EDs to fill the gap. Frequent users of the ED tend to have chronic health problems, and while most ED patients identify a place where they usually receive care, few have had contact with their physicians prior to seeking ED care (Milbrett & Halm 2009; Weber et al. 2008). Increased use of the ED is associated with a lack of access to primary care services (Rust et al. 2008), and a majority of ED visits take place on the weekends or on a weekday after physician office hours (Pitts et al. 2010), or by patients who were discharged from the hospital within the last seven days (Burt et al. 2008).

If a patient is admitted to the hospital, they are likely to be cared for by a physician they have never met. Over 50% of all hospitals employ hospitalists. Hospitalists are physicians who do not see patients in an office-based setting, and who often provide all inpatient coverage for primary care physicians who have chosen to practice in an outpatient setting. While this model can actually improve timeliness of care in the hospital, continuity of care across settings becomes more challenging (Hamel et al. 2009). For example, almost 20% of Medicare patients discharged from hospitals are readmitted within 30 days, and 34% are rehospitalized within 90 days (Jencks et al. 2009). However, over 50% of patients who were readmitted within 30 days had not seen their primary physician for a follow-up visit at any time after discharge.

The length of stay for hospitalized patients has decreased dramatically. Over 38% of hospitalized patients are elderly (age 65 and older) and have an average length of stay of only five days. Admissions are driven primarily by Medicare guidelines concerning financial reimbursement. Medicare guidelines allow very little time for physicians and nurses to sort out care issues surrounding and associated with chronic illnesses.

Discharge planning is focused on matching the patient with community services needed after hospital discharge. This can be a challenging task for discharge planners because the non-hospital service providers are under no obligation to accept referrals, and may make choices based solely on the reimbursement available for that service (Popejoy et al. 2009). Nursing home placement, home care services, equipment needed at home, or personal services necessary for continued care may not be available. Additionally, patient education tends to be focused on survival skills for that particular diagnosis. In a recent survey of Medicare beneficiaries, 19% indicated that when they were discharged from the hospital they were not provided information about home care services or instructions on follow-up care or problems they might encounter and whom to contact with questions (Centers for Medicare & Medicaid Services [CMS] 2010).

The shortage of primary care physicians, and the delivery structure within their offices, has resulted in work days with patients’ appointments scheduled at 15-minute increments, leaving little or no time for coordination of care. Additionally, a lack of involvement with specialists and hospitalists, as well as limited or no involvement in care transitions, impedes the management of their patients with multiple chronic illnesses (Bodenheimer et al. 2009c).

In this fragmented delivery structure, obtaining accurate medication lists for patients on hospital admission and ensuring patient discharge with appropriate medications (medication reconciliation) is one of the biggest quality challenges that health systems face. The percentage of patients who have inaccurate or incomplete medication lists at the time of admission can be as high as 69% (Slain et al. 2008). Over half of patients (54%) often experience at least one potentially adverse drug event while hospitalized; 70% are attributable to inaccurate admission histories, and 30% to errors in reconciling the medication history with discharge orders when patients are transitioned from a long-term care facility to the acute care setting (Pippins et al. 2008). Over 27% of adverse drug events are considered potentially harmful (Pippins et al. 2008). The results are particularly concerning in the care of hospitalized elderly adults since the likelihood of adverse drug events steadily increases with the number of co-morbidities (Page et al. 2010). A lack of effective care coordination at key transition points can be devastating.

Financing and payment barriers

While it is somewhat difficult to determine a direct causal relationship, our fragmented health system structure is supported by a system of financial incentives that perpetuate a lack of care coordination. In 2007, total health expenditures accounted for 16% of the gross domestic product (National Center for Health Statistics 2010). While there are a number of different health insurance plans and payers, the largest is the federal government. The Medicare program alone accounts for 13% of the annual federal budget (Satiani 2009). With health care spending and federal deficits escalating, the Medicare program has become a political focus for examining the overhauling of health care delivery.

TheMedicare program originally was conceptualized as an expansion of Social Security benefits to provide limited coverage of inpatient hospital care for the elderly. It was expanded to include physician and state welfare services and became law in 1965 with Medicare Part A covering hospitals, Medicare Part B covering physician services, and Medicaid providing support to individual states for indigent health care (Blumenthal & Morone 2008). When Medicare was initially enacted into law, the financing structure of health care was largely fee-for-service payments to physicians and hospitals. There was little history on which to base cost estimates, and no controls or standards to define appropriate levels of service. Essentially, the more services a hospital or physician provided, the more they were paid.

In 1984, a new method for hospital reimbursement was enacted for the Medicare program. Hospitals started receiving one payment for an episode of care based on Diagnosis Related Groups (DRGs). Hospitals began assuming financial risk for each hospital stay based on the predicted costs for a particular diagnosis rather than payments for every service performed. DRGs placed emphasis on hospital length of stay and utilization of services, but physician fee-for-service payments did not change. This placed hospitals and physicians on different incentive platforms, since each had different financial incentives and reimbursement mechanisms for the care they provided (Goldsmith 2010). Neither method of payment, however, encouraged care beyond a single episode, thus furthering fragmentation of services.

With the need for even further cuts in Medicare spending, physician payments were redesigned in 1992 with the Resource-Based Relative Value Scale (RBRVS; Johnson & Newton 2002). The RBRVS was a complicated system with a fee structure based on the type of work, practice environment, and malpractice costs of physician services, but it was still a fee-for-service method that did not control quality or necessity of testing (Verrilli et al. 1996). In addition, the fee scale tended to support procedures at a much higher rate than physician activities involving patient management and evaluating outcomes. This resulted in declining reimbursement for primary care services, and escalating payments to specialists who performed multiple procedures. With decreasing revenue, primary care physicians increased patient volume, leaving little time for coordination of care necessary for patients with chronic illnesses (Bodenheimer et al. 2009c). This payment structure continues today. Additionally, both home health care and skilled nursing facilities (SNFs) now receive payments based on episodes of care with scales designed specifically for those types of services. Pharmacy benefits, as well as managed care options through private insurance companies, have also been added to the Medicare program.

This complicated Medicare payment structure supports a silo delivery system wherein each provider is focused on one episode of care within a defined period of time. For hospitals, the focus is on a single hospitalization. For SNFs, the focus is on skilled needs within a defined timeframe. Home care has a similar focus, with benefits paid based on an acuity adjusted 60-day episode of care (Davitt & Choi 2008). Physicians continue to receive payments for the individual services they provide. Pharmacies function independently with private plans covering Medicare patients. At no point is there any financial incentive for these various providers to work as a team across multiple episodes of care or to achieve continuity of care for an individual patient.

To complicate this picture even further, some Medicare beneficiaries may also qualify for additional benefits through the Medicaid program. Medicaid is a federally supported program designed to help states meet the health care needs of low income citizens, targeting children, adults, and individuals with disabilities. People who reside in residential and long-term care facilities are also eligible for coverage. Medicaid benefits and services vary significantly from state to state. Medicaid beneficiaries must meet annual eligibility requirements, and many states set even more frequent eligibility periods. The recertification process results in patients moving in and out of eligibility based on their current life situations. These interruptions in coverage affecting individuals with chronic illnesses can lead to serious deterioration in disease management and result in multiple hospitalizations (Bindman et al. 2008; Hall et al. 2008).

Reducing costs and redesigning financing is a major focus of health care reform. The PPACA includes provisions for reimbursement based on quality of care outcomes to health care providers. In addition, the law established criteria to explore and financially support delivery models where coordinated care is provided across all levels and settings of care, especially for individuals suffering from chronic illnesses (Goldsmith 2010). Regardless of whether the payment system is driving care or is simply a by-product of a poorly designed system, there is widespread acknowledgement that current methods for delivery and payment of health care are not acceptable, affordable, or sustainable into the foreseeable future.

Workforce concerns

According to the Institute of Medicine (IOM 2008) the current health care workforce lacks essential education and training in the care of adults – particularly older adults – with chronic illnesses. At the same time, the workforce is not nearly large enough to care for the rapid aging of America, especially with the advancing influx of baby boomers. This scarcity of qualified health care providers is expected to continue to rise along with this aging population. By 2030, it is estimated that we will need an additional 3.5 million health care providers, a 35% increase over current levels, just to maintain the current ratio of providers to the total population (IOM 2008). Providers who are in short supply include nurses, primary care physicians, physician assistants, geriatric social workers, nursing assistants, and home care and home health aids (Bureau of Labor Statistics 2010).

Comprehensive care coordination calls for new models of delivering chronic illness care that will demand new skills and expertise from providers – especially from nurses and primary care physicians – that are not emphasized in today’s health care environment (Bohmer 2010; Margolius & Bodenheimer 2010). These skills involve: designing care around the patient (that is, adopting patient-centered care); communicating and collaborating in multidisciplinary care teams; evaluating and continuously improving the quality and safety of patient care; monitoring patients over time, using and sharing information technology; and viewing care from the broadest perspective, which is population-based care.

To address these workforce barriers, various solutions have been proposed. Examples of solutions include: substantial changes in financial incentives for redesigned primary care delivery and reimbursement for primary care physicians and nurse practitioners; substantial increases in funding for medical and nursing education and training with a focus on geriatrics; and legislative proposals that a certain percentage of clinicians practice in primary care with appropriate financial and educational incentives for doing so (Bodenheimer et al. 2009b).

Health information technology

As described above, efforts to effectively coordinate and manage chronic illnesses have been hampered by a number of barriers, including a fragmented health care system and the need for more coordination across sites of care; the difficulty which people with chronic illnesses have in paying for their care; the current reimbursement system does not reward key elements of chronic illness care; and the need for enhanced medical and nursing training and education, which places an increasing focus on chronic care.

Ourhealth care system is currently not well equipped to address these concerns. Because of the highly fragmented nature of health care, patient information is stored in many locations, primarily in paper-based forms with limited access. As a result, clinicians often do not have comprehensive patient information at the point of care, when it is most needed. It also impedes having the necessary information to measure performance and facilitate quality improvement of patient populations. Additionally, patients do not have access to necessary information they need to help manage their own health and health care.

Health information technology (HIT) holds great promise for addressing many of these barriers to comprehensive care coordination and is a key component in managing patient populations and complex communications within a team environment (Hillestad et al. 2005). HIT facilitates access to and retrieval of clinical data from different entities involved in the care delivery system, which can result in more timely, efficient, effective, equitable, patient-centered care (Marchibroda 2008). For example, HIT can compile individual patient information related to care performed by multiple clinicians, hospitals, and community providers, and provide different views of this information by the interdisciplinary care team, thus enhancing care coordination activities. HIT systems can also trigger individual patient alerts and reminders to support clinicians and patients regarding tests that need to be performed or medications that need to be prescribed or filled. The connection of HIT to personal health records can improve patient engagement, by not only providing additional information to support self-management, but also creating a mechanism for patients to input their own experiences to support the work of the care team. Furthermore, the use of remote devices that connect to personal health records and clinical HIT applications can enable timelier, more accurate capture of specific information that is critical to chronic disease management.

Researchers estimate savings of approximately $81 billion over 15 years (Girosi et al. 2005), and as many as 200,000 adverse drug events per year could be prevented (RAND Health 2005) if HIT was widely adopted. Despite the advantages outlined above and potential financial savings, HIT adoption rates are low. Survey estimates indicate that approximately 24% of physician offices, 16% of solo practitioners, and 39% of large physician practices are using electronic health records (EHR; Blumenthal et al. 2006). Based on a 2009 study, only 8% of responding hospitals reported basic implementation of an EHR system, while only 2% reported having achieved successful comprehensive integration (Jha 2009). The cost of establishing EHR within a hospital setting can be extensive. Depending on the size of the hospital, EHR systems can cost anywhere between $35,000 to $50,000 per provider (Jha et al. 2009; Hildreth 2010). Inadequate capital for purchasing and maintaining the EHR system are often cited as the main reason for transition delays (DePhillips 2007).

Little is known about how to create and successfully implement a comprehensive HIT system that will positively impact comprehensive care coordination for patients with complex chronic illnesses. In a systematic literature review, Dorr and colleagues (2007) identified HIT components important in supporting this concept. Components of an HIT system that were closely correlated with positive outcomes included a connection of an electronic medical record, computerized prompts, population management, including reports and feedback, specialized decision support, electronic scheduling, and personal health records. Barriers included costs, data privacy and security concerns, and failure to consider workflow issues.

Self-management and health literacy

Chronic illnesses are irreversible, latent, and incurable (Lubkin & Larsen 2008). They can profoundly affect a person’s physical, emotional, and mental health status and make it difficult to complete simple tasks or carry on with daily routines, thereby negatively impacting their overall quality of life. Although health professionals assume responsibility for the medical management of chronic illness, the patient assumes responsibility for the day-to-day management of his or her own chronic illness. All individuals with chronic illnesses engage in self-management behaviors by deciding what to eat and drink, whether or not to exercise, and if they will take their prescription medications. To help chronically ill patients succeed in improving their health-related behavior, health care providers continually engage in self-management support; patient self-management is a prominent component of comprehensive care coordination (Holman & Lorig 2004).

The purpose of self-management support is to help chronically ill patients become actively involved in their treatment (Bodenheimer et al. 2005; Holman & Lorig 2004) and involves two interrelated activities. The first is helping patients to be informed about their chronic illnesses, and the second is trying to work with patients and their caregivers to make informed medical decisions and become more self-motivated. Thus, self-management support involves both information giving and sharing and collaborative decision making to assist patients in their self-directed learning.

Several strategies and techniques have been used in a variety of self-management programs to assist providers and patients in collaborative decision making, including establishing an agenda; information giving (ask, tell, ask); assessing readiness to change (motivational interviewing); and goal setting (Bodenheimer et al. 2005). Using a collaborative approach to patient self-management support, an agenda for each visit is negotiated between the patient and clinician, focusing on the patient’s needs and/or wants. Elicit, respond, elicit (ask, tell, ask) is a technique for information giving and sharing that seeks to overcome too little information (insufficient) or too much information (overload) given in the teaching/learning encounter that is directed by the patient. Motivational interviewing is a useful technique for assessing readiness to change by focusing on the behavior’s importance to the individuals and their confidence in actually making a behavior change (Rollnick et al. 2000). Goal setting is used to help patients in agreeing to concrete, short-term goals, accompanied by action plans that are highly specific.

A variety of self-management programs have been developed and implemented for patients with chronic illnesses, especially for older adults with specific illnesses. They have achieved various levels of success, especially for patients with diabetes, hypertension, and arthritis, but there is no agreement on the essential components that make them successful (Chodosh et al. 2005). However, self-management support programs have not been evaluated within the context of a multi-component, comprehensive, randomized intervention. Overall, the evidence does suggest that: self-management support does improve health-related behaviors; providing information is a necessary, but not sufficient, intervention to improve health-related behaviors; informed, motivated patients tend to have better health-related behaviors and clinical outcomes; establishing an agenda, goal setting, and motivational interviewing have shown success with older adults (Abramowitz et al. 2010; Bodenheimer et al. 2005; Flocke et al. 2009; Hibbard et al. 2004; Paradis et al. 2010). Whatever method or technique works best in supporting self-management, patients with multiple chronic illnesses have identified five skills they need to help them manage their diseases: correctly using medications, monitoring important disease symptoms, improving sleep, managing pain, and reducing stress (Noel et al. 2007).

Although it is difficult to identify specific components that contribute to the success of self-management support, a person’s level of health literacy, or their ability to understand and appropriately act upon health-related information, is directly related to their ability to care for themselves or their loved ones (Villaire & Mayer 2007). Although there is no agreed upon standard definition, health literacy is defined as the ability to read, understand, and act on health information in order to make appropriate health decisions.

It has been estimated that upwards of 45% of the U.S. adult population has literacy skills at or below an eighth-grade reading level. Inadequate health literacy increases steadily with age, from 16% of adults aged 65 to 69 to 58% of those over age 85 (Gazmararian et al. 1999). Older adults with low health literacy have trouble reading health information materials, following prevention recommendations, understanding basic medical instructions, and adhering to medication regimes. Health literacy levels are lowest among the elderly, the uneducated, lower socioeconomic levels, minority populations, and those with limited English proficiency (Kutner 2006). Limited health literacy skills are associated with increased risks of mortality, greater difficulty with self-management skills (managing a chronic illness), poor health status, impaired ability to remember and follow treatment recommendations, and reduced medication adherence, as well as a reduced ability to navigate within the health care system and a greater likelihood of hospitalizations due to poor self-management skills (Gazmararian et al. 2003; Persell et al. 2007; Powell et al. 2007; Schillinger et al. 2002; Sudore et al. 2006).

A patient’s inability to understand health care information adds another barrier in establishing a collaborative, clinician–patient relationship and in improving the patient’s decision-making skills. For example, compared to adults with higher health literacy, adults with lower health literacy skills tend to ask fewer questions about their illnesses and medical care issues, are more likely to not understand what the clinician said, and are less likely to use medical terminology, refer to their medications by name, or request additional information (Katz et al. 2007). Several instruments are available to clinicians to help them assess health literacy and identify patients who have poor literacy skills. The instruments are easy to administer and interpret and do not require undue patient information overload. The Rapid Estimate of Adult Literacy in Medicine, Revised (REALM-R) is a brief screening instrument that can be used to assess a person’s ability to read common medical words (Bass et al. 2003), and the Medication Knowledge Assessment can be used to determine a person’s knowledge about their medications and their ability to read and comprehend information necessary for appropriate medication use, and may serve as the basis of a focused knowledge improvement plan (American Society on Aging and the American Society of Consultant Pharmacists Foundation 2006).

Summary

The barriers to effective care coordination are numerous, but the imperative to succeed is even more compelling. Chronically ill patients suffer for several reasons, including readmissions to hospitals, returns to EDs, and polypharmacy errors. Health care providers are frustrated with a system that does not support the care of these high-need patients, and they have difficulty providing appropriate care with the constraints placed on them by the current reimbursement structure.

Effective coordinated care provides a solution where patients and providers can work together to overcome many of the barriers outlined in this chapter. Through coordination, fragmentation of care can be minimized. Unnecessary costs of care including unnecessary readmissions can be reduced or eliminated. Errors caused by incomplete medication information can be reduced significantly. Primary care physicians and nurses working together with the patient in a realistic delivery model can improve satisfaction for those health care providers and make the roles attractive to help meet future workforce needs. By providing the patients with tools that they need to manage their health and involving them in the process, long-term positive health outcomes are possible. It’s time for all of us to learn how to do this.

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