August 7, 2019

Successful models of comprehensive care for older adults with chronic conditions: evidence for the Institute of Medicine’s “retooling for an aging America” report

J Am Geriatr Soc, 57;12:2328-37 Authors: Boult, C., Green, A. F., Boult, L. B., Pacala, J. T., Snyder, C., Leff, B., The quality of chronic care in America is low, and the cost is high. To help inform efforts to overhaul the ailing U.S. healthcare system, including those related to […]
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J Am Geriatr Soc, 57;12:2328-37 Authors: Boult, C., Green, A. F., Boult, L. B., Pacala, J. T., Snyder, C., Leff, B., The quality of chronic care in America is low, and the cost is high. To help inform efforts to overhaul the ailing U.S. healthcare system, including those related to the ""medical home,"" models of comprehensive health care that have shown the potential to improve the quality, efficiency, or health-related outcomes of care for chronically ill older persons were identified. Using multiple indexing terms, the MEDLINE database was searched for articles published in English between January 1, 1987, and May 30, 2008, that reported statistically significant positive outcomes from high-quality research on models of comprehensive health care for older persons with chronic conditions. Each selected study addressed a model of comprehensive health care; was a meta-analysis, systematic review, or trial with an equivalent concurrent control group; included an adequate number of representative, chronically ill participants aged 65 and older; used valid measures; used reliable methods of data collection; analyzed data rigorously; and reported significantly positive effects on the quality, efficiency, or health-related outcomes of care. Of 2,714 identified articles, 123 (4.5%) met these criteria. Fifteen models have improved at least one outcome: interdisciplinary primary care (1), models that supplement primary care (8), transitional care (1), models of acute care in patients' homes (2), nurse-physician teams for residents of nursing homes (1), and models of comprehensive care in hospitals (2). Policy makers and healthcare leaders should consider including these 15 models of health care in plans to reform the U.S. healthcare system. The Centers for Medicare and Medicaid Services would need new statutory flexibility to pay for care by the nurses, social workers, pharmacists, and physicians who staff these promising models.
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http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2009.02571.x/abstract

August 7, 2019

Comprehensive primary care for older patients with multiple chronic conditions: “Nobody rushes you through”

JAMA, 304;17:1936–43 Authors: Boult, C., Wieland, G. D. Older patients with multiple chronic health conditions and complex health care needs often receive care that is fragmented, incomplete, inefficient, and ineffective. This article describes the case of an older woman whose case cannot be managed effectively through the customary approach of […]
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JAMA, 304;17:1936–43 Authors: Boult, C., Wieland, G. D. Older patients with multiple chronic health conditions and complex health care needs often receive care that is fragmented, incomplete, inefficient, and ineffective. This article describes the case of an older woman whose case cannot be managed effectively through the customary approach of simply diagnosing and treating her individual diseases. Based on expert consensus about the available evidence, this article identifies 4 proactive, continuous processes that can substantially improve the primary care of community-dwelling older patients who have multiple chronic conditions: comprehensive assessment, evidence-based care planning and monitoring, promotion of patients' and (family caregivers') active engagement in care, and coordination of professionals in care of the patient--all tailored to the patient's goals and preferences. Three models of chronic care that include these processes and that appear to improve some aspects of the effectiveness and the efficiency of complex primary care--the Geriatric Resources for Assessment and Care of Elders (GRACE) model, Guided Care, and the Program of All-inclusive Care for the Elderly (PACE)--are described briefly, and steps toward their implementation are discussed.
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http://jama.ama-assn.org/content/304/17/1936.abstract

August 7, 2019

The Promise of Care Coordination: Models that Decrease Hospitalizations and Improve Outcomes for Medicare Beneficiaries with Chronic Illnesses

Brown R. The National Coalition On Care Coordination.The Promise of Care Coordination: Models that Decrease Hospitalizations and Improve Outcomes for Medicare Beneficiaries with Chronic Illnesses. http://www.nyam.org/social-work-leadership-institute/docs/N3C-Promise-of-Care-Coordination.pdf. March 2009. Accessed April 26, 2013. A synthesis of the literature on best practices in care management and transitions of care models as well […]
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Brown R. The National Coalition On Care Coordination.The Promise of Care Coordination: Models that Decrease Hospitalizations and Improve Outcomes for Medicare Beneficiaries with Chronic Illnesses. http://www.nyam.org/social-work-leadership-institute/docs/N3C-Promise-of-Care-Coordination.pdf. March 2009. Accessed April 26, 2013. A synthesis of the literature on best practices in care management and transitions of care models as well as outcomes.
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http://www.nyam.org/social-work-leadership-institute/docs/N3C-Promise-of-Care-Coordination.pdf

August 7, 2019

CMAG Case Management Adherence Guidelines. Version 2.0

Case Management Society of America. Case Management Adherence Guidelines. Version 2.0.http://www.cmsa.org/portals/0/pdf/CMAG2.pdf.Published June 2006. Accessed 7/9/14. Guidelines form the case Management Society of America for improving patient adherence to medication therapies
Case Management Society of America. Case Management Adherence Guidelines. Version 2.0.http://www.cmsa.org/portals/0/pdf/CMAG2.pdf.Published June 2006. Accessed 7/9/14. Guidelines form the case Management Society of America for improving patient adherence to medication therapies
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http://www.cmsa.org/portals/0/pdf/CMAG2.pdf

August 7, 2019

National Association of Social Workers, Case Management Society of America, and NTOCC Case/Care Management Guidelines.

National Association of Social Workers, Case Management Society of America, and NTOCC Case/Care Management Guidelines. http://www.cmsa.org/portals/0/pdf/publiccomment/DraftCareCaseManagementGuidelines.pdf. Draft Published June 2007. Accessed 7/9/14. These guidelines are proposed to provide a framework for assessment to facilitate both transitions between levels of care and communication among professionals and with clients. Examples include Assessment […]
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National Association of Social Workers, Case Management Society of America, and NTOCC Case/Care Management Guidelines. http://www.cmsa.org/portals/0/pdf/publiccomment/DraftCareCaseManagementGuidelines.pdf. Draft Published June 2007. Accessed 7/9/14. These guidelines are proposed to provide a framework for assessment to facilitate both transitions between levels of care and communication among professionals and with clients. Examples include Assessment and Coordination of Care Communication Checklist.
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http://www.cmsa.org/portals/0/pdf/publiccomment/DraftCareCaseManagementGuidelines.pdf

August 7, 2019

Joint Commission Center for Transforming Healthcare Releases Tool to Tackle Miscommunication Among Caregivers

The Joint Commission Center for Transforming Healthcare released a new Hand-off Communications Targeted Solutions Tool™ (TST) to assist health care organizations with the process of passing necessary and critical information about a patient from one caregiver to the next, or from one team of caregivers to another, to prevent miscommunication-related […]
The Joint Commission Center for Transforming Healthcare released a new Hand-off Communications Targeted Solutions Tool™ (TST) to assist health care organizations with the process of passing necessary and critical information about a patient from one caregiver to the next, or from one team of caregivers to another, to prevent miscommunication-related errors.
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http://www.centerfortransforminghealthcare.org/center_transforming_healthcare_tst_hoc/

August 7, 2019

One Patient, Many Places: Managing Health Care Transitions. A Report from the HMO Workgroup on Care Management

HMO Workgroup on Care Management. One Patient, Many Places: Managing Health Care Transitions. AAHP-HIAA Foundation, Washington DC. http://www.caretransitions.org/documents/One%20Patient%20RWJ%20Report.pdf . Published February 2004. This report addresses how Managed Care Organizations can improve the quality of transitions of care for adult patients with complex acute or chronic conditions. Includes best practices, recommendations […]
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HMO Workgroup on Care Management. One Patient, Many Places: Managing Health Care Transitions. AAHP-HIAA Foundation, Washington DC. http://www.caretransitions.org/documents/One%20Patient%20RWJ%20Report.pdf . Published February 2004. This report addresses how Managed Care Organizations can improve the quality of transitions of care for adult patients with complex acute or chronic conditions. Includes best practices, recommendations for action, and tools.
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http://www.caretransitions.org/documents/One%20Patient%20RWJ%20Report.pdf

August 7, 2019

NTOCC: Cultural Competence—Essential Ingredient for Successful Transitions of Care

Health care professionals increasingly recognize the crucial role that culture plays in the health care of a client or patient and the need to deliver services in a culturally competent manner. Cultural competence is essential to successful, client-/patient-centered transitions of care. This tool provides information about culture and cultural competence, […]
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Health care professionals increasingly recognize the crucial role that culture plays in the health care of a client or patient and the need to deliver services in a culturally competent manner. Cultural competence is essential to successful, client-/patient-centered transitions of care. This tool provides information about culture and cultural competence, as well as strategies and resources to enhance professionals’ capacity to deliver culturally competent services during transitions of care.
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http://www.ntocc.org/Portals/0/PDF/Resources/CulturalCompetence.pdf

August 7, 2019

Care management of patients with complex health care needs: Research Synthesis Report No. 19

Brown R, Peikes D, Peterson G. Care management of patients with complex health care needs: Research Synthesis Report No. 19. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2009/rwjf49853/subassets/rwjf49853_1. December 2009. Accessed April 17, 2013. This synthesis looks at the evidence and explores the potential for care management to improve quality of care and reduce costs for people […]
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Brown R, Peikes D, Peterson G. Care management of patients with complex health care needs: Research Synthesis Report No. 19. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2009/rwjf49853/subassets/rwjf49853_1. December 2009. Accessed April 17, 2013. This synthesis looks at the evidence and explores the potential for care management to improve quality of care and reduce costs for people with complex health care needs. This synthesis addresses the following questions: 1. What is care management? 2. How are patients identified for care management programs? 3. Do research-based care management programs enhance quality and reduce costs for patients with complex health care needs? 4. What are the characteristics of successful care management programs? 5. How have research-based care management programs been adapted to real-world treatment settings? 6. How do payment policies influence the creation and success of care management programs?
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https://www.rwjf.org/content/dam/farm/reports/issue_briefs/2009/rwjf49853/subassets/rwjf49853_1

August 7, 2019

Patient Outcomes at 26 Months in the Patient-Centered Medical Home National Demonstration Project

Jaen CR, et al.Patient Outcomes at 26 Months in the Patient-Centered Medical Home National Demonstration Project. Annals of Family Medicine.2010;8(S-1):S57-S67. http://www.annfammed.org/content/8/Suppl_1/S57.abstract .Accessed 7/10/14 PURPOSE The purpose of this study was to evaluate patient outcomes in the National Demonstration Project (NDP) of practices’ transition to patient-centered medical homes (PCMHs).
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Jaen CR, et al.Patient Outcomes at 26 Months in the Patient-Centered Medical Home National Demonstration Project. Annals of Family Medicine.2010;8(S-1):S57-S67. http://www.annfammed.org/content/8/Suppl_1/S57.abstract .Accessed 7/10/14 PURPOSE The purpose of this study was to evaluate patient outcomes in the National Demonstration Project (NDP) of practices’ transition to patient-centered medical homes (PCMHs).
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http://www.annfammed.org/cgi/content/abstract/8/Suppl_1/S57