Comprehensive care coordination for chronically ill adults / edited by Cheryl Schraeder, Paul Shelton.

Includes index.

Comprehensive Care Coordinationfor Chronically Ill Adults; Contents; Editors and Contributors; Acknowledgments; Introduction; PART 1 THEORETICAL CONCEPTS; 1 Chronic illness; 2 Overview; 3 Promising practices in acute/primary care; 4 Promising practices in integrated care; 5 Intervention components; 6 Evaluation methods; 7 Health information technology; 8 Financing and payment; 9 Education of the interdisciplinary team; PART 2 PROMISING PRACTICES; SECTION 1 PRIMARY CARE MODELS; 10 Coordination of care by guided care interdisciplinary teams; 11 Care management plus; 12 Medicare coordinated care SECTION 2 TRANSITIONAL CARE MODELS13 The care transitions intervention; 14 Enhanced Discharge Planning Program at Rush University Medical Center; SECTION 3 INTEGRATED MODELS; 15 Summa Health System and Area Agency on Aging Geriatric Evaluation Project; 16 Program of All-Inclusive Care for the Elderly (PACE); SECTION 4 MEDICAID MODELS; 17 Introduction to Medicaid care management; 18 The Aetna Integrated Care Management Model: a managed Medicaid paradigm 19 King County Care Partners: a community based chronic care management system for Medicaid clients with co-occurring medical, mental, and substance abuse disorders20 Predictive Risk Intelligence SysteM (PRISM): a decision-support tool for coordinating care for complex Medicaid clients; 21 High-risk patients in a complex health system: coordinating and managing care; 22 The SoonerCare Health Management Program; SECTION 5 PRACTICE CHANGE; 23 Introduction: practice change fellows initiatives 24 Interdisciplinary care of chronically ill adults: communities of care for people living with congestive heart failure in the rural setting25 Collaborative care treatment of late-life depression: development of a depression support service; 26 Geriatric Telemedicine: supporting interdisciplinary care; 27 Integrated Patient-Centered Care: the I-PiCC pilot; SECTION 6 MEDICARE MANAGED CARE; 28 Longitudinal care management: High risk care management; SECTION 7 INTERNATIONAL CARE COORDINATION; 29 The experiences in the Republic of Korea; Index

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.