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Managing Care for Adults with Chronic Conditions

Delivering & Coordinating Services

Care coordination is often made difficult by the inadequacy of information systems and by payment systems that do not recognize its importance. For these and other reasons, health care providers often devote little time to assessing a patient's functional ability, providing instruction in behavior change or self-care, or addressing emotional or social distress.

Failure to focus on these issues can lead to fragmented care and limited communication across settings and providers. Inadequate care coordination can be costly for patients and other payers when it leads to unnecessary nursing home placements, inappropriate hospitalizations, or adverse drug interactions.

As a result, States and other payers have begun to implement more complex interventions than those focused solely on prevention and identification of chronic conditions. These more intensive efforts are designed to influence the delivery of care and to focus attention on the coordination of health and supportive services. They include the following:

Medicare Care Coordination Demonstrations

The Centers for Medicare & Medicaid Services (CMS) has funded fifteen Medicare demonstrations of case management and disease management programs. The four-year demonstrations, which began in 2001, are designed to test whether a variety of care coordination programs can be applied to Medicare fee-for-service settings in order to:

  • Improve the quality of care for chronically ill beneficiaries.
  • Encourage the more efficient use of health care services.
  • Reduce health care costs.

The Chronic Care Model

The Chronic Care Model is designed to foster productive interactions between patients and providers. The Model was developed at the MacColl Institute for Healthcare Innovation and incorporates the community, the health system, self-management support, delivery system design, decision support, and clinical information systems. The Model emphasizes self-management, believing that patient participation and buy-in is critical to success.

  • The Washington State Diabetes Collaborative is based on the Chronic Care Model. Sponsored by the Washington State Department of Health, Qualis Health (a non-profit, health care quality improvement organization), and the MacColl Institute, the Collaborative is designed to improve care for persons with diabetes and offers a template for managing a variety of chronic illnesses.

  • Health Disparities Collaboratives, conducted by the Health Resources and Services Administration (HRSA), are also based on the Chronic Care Model. The Collaboratives combine the Chronic Care Model with a rapid cycle quality improvement model to support Community Health Centers in their efforts to transform their healthcare delivery systems from an acute care model to the chronic care model.

Provider-based Partnerships

Seamless systems that cross settings, providers, and financing can improve care for people with chronic conditions and disabilities.

  • The Akron (OH) City Hospital through a partnership with the local Area Agency on Aging (AAA) has created Acute Care for Elders (ACE) units and interdisciplinary care teams to improve health outcomes. The teams includes a geriatrician, a geriatric clinical nurse specialist, nurses with extensive experience caring for hospitalized older patients, a social worker, physical and occupational therapists, a dietitian, and a pharmacist. A registered nurse assessor from the AAA works with the care team to develop an integrated care plan. The ACE intervention is designed to prevent patient decline, decrease mortality, and decrease hospital length of stay. Its units partner with skilled nursing facilities to help achieve these goals.

The Managed Fee-for-Service Model

Primary care case management (PCCM) programs have experienced significant growth in recent years, and this growth, along with managed care's potential to improve quality and reduce costs, has increased interest in PCCM and other managed fee-for-service (MFFS) models for people with chronic conditions and persons who are dually eligible.

States that establish MFFS programs act much like a managed care organization might. They enter into contractual arrangements with selected providers, specify a provider or agency to coordinate care, establish enrollment criteria, conduct consumer and provider education, analyze claims data, issue practice protocols, and pay claims. The States play an active role in service delivery focusing on multiple chronic conditions, care coordination, quality improvement interventions, and performance measurement. However, unlike managed care, most or all payments for services to beneficiaries remain fee-for-service with little or no risk to providers.

  • The Georgia Service Options Using Resources in a Community Environment (SOURCE) is an enhanced primary care case management program serving frail elders and adults with disabilities. Georgia's SOURCE program is designed to delay or prevent the need for hospital and nursing home admissions by integrating primary medical care with supportive home care services. Its case management is financed under the State's 1915(b) waiver, and home and community based services are financed by the 1915(c) waiver. Evaluation of 1998-99 claims data suggests lower overall Medicaid costs per SOURCE enrollee (compared to cohort), lower percentage of discharges to nursing homes, and reduced length of hospital stay.

  • The Vermont Independence Project (VIP) offers another managed fee-for-service model. VIP links case managers in Area Agencies on Aging with primary care physicians to improve coordination through enhanced case management services. The case management services are provided in primary care practices that serve a large proportion of children and adults with complex care needs, including dual-eligibles.


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