Table of Contents

Editors and Contributors ix

Acknowledgments xv

Introduction xvii

Part 1 Theoretical Concepts

1 Chronic illness 3
Paul Shelton, EdD, Cheryl Schraeder, RN, PhD, FAAN, Michael K. Berkes, BS, MSW Candidate, and Benjamin Ronk, BA

2 Overview 25
Cheryl Schraeder, RN, PhD, FAAN, Paul Shelton, EdD, Linda Fahey, RN, MSN, Krista L. Jones, DNP, MSN, ACHN, RN, and Carrie Berger, BA, MSW Candidate

3 Promising practices in acute/primary care 39
Randall S. Brown, PhD, Arkadipta Ghosh, PhD, Cheryl Schraeder, RN, PhD, FAAN, and Paul Shelton, EdD

4 Promising practices in integrated care 65
Patricia J. Volland, MSW, MBA, and Mary E. Wright

5 Intervention components 87
Cheryl Schraeder, RN, PhD, FAAN, Cherie P. Brunker, MD, Ida Hess, MSN, FNP-BC, Beth A. Hale, PhD, RN, Carrie Berger, BA, MSW Candidate, and Valerie Waldschmidt, BSE

6 Evaluation methods 127
Robert Newcomer, PhD, and L. Gail Dobell, PhD

7 Health information technology 141
David A. Dorr, MD, MS and Molly M. King, BA

8 Financing and payment 167
Julianne R. Howell, PhD, Robert Berenson, MD, and Patricia J. Volland, MSW, MBA

9 Education of the interdisciplinary team 191
Emma Barker, MSW, Patricia J. Volland, MSW, MBA, and Mary E. Wright

Part 2 Promising Practices

Section 1 Primary Care Models

10 Coordination of care by guided care interdisciplinary teams 209
Chad Boult, MD, MPH, MBA, Carol Groves, RN, MPA, and Tracy Novak, MHS

11 Care management plus 221
Cherie P. Brunker, MD, David A. Dorr, MD, MS, and Adam B. Wilcox, PhD

12 Medicare coordinated care 229
Angela M. Gerolamo, PhD, APRN, BC, Jennifer Schore, MSW, MS, Randall S. Brown, PhD, and Cheryl Schraeder, RN, PhD, FAAN

Section 2 Transitional Care Models

13 The care transitions intervention 263
Susan Rosenbek, RN, MS, and Eric A. Coleman, MD, MPH

14 Enhanced Discharge Planning Program at Rush University Medical Center 277
Anthony J. Perry, MD, Robyn L. Golden, LCSW, Madeleine Rooney, MSW, LCSW, and Gayle E. Shier, MSW

Section 3 Integrated Models

15 Summa Health System and Area Agency on Aging Geriatric Evaluation Project 293
Kyle R. Allen, DO, AGFS, Joseph L. Ruby, BA, MA, Susan Hazelett, RN, MS, Carolyn Holder, MSN, RN, GCNS-BC, Sandee Ferguson, RN, BBA, MS, Fellow, and Phyllis Yoders, RN, BSN

16 Program of All-Inclusive Care for the Elderly (PACE) 303
Brenda Sulick, PhD, and Christine van Reenen, PhD

Section 4 Medicaid Models

17 Introduction to Medicaid care management 317
Allison Hamblin, MSPH, and Stephen A. Somers, PhD

18 The Aetna Integrated Care Management Model: a managed Medicaid paradigm 325
Robert M. Atkins, MD, MPH, and Mark E. Douglas, JD, MSN, RN

19 King County Care Partners: a community based chronic care management system for Medicaidclients with co-occurring medical, mental, and substance abuse disorders 339
Daniel S. Lessler, MD, MHA, Antoinette Krupski, PhD, and Meg Cristofalo, MSW, MPA

20 Predictive Risk Intelligence SysteM (PRISM): a decision-support tool for coordinating care forcomplex Medicaid clients 349
Beverly J. Court, MHA, PhD, David Mancuso, PhD, Chad Zhu, MS, and Antoinette Krupski, PhD

21 High-risk patients in a complex health system: coordinating and managing care 361
Maria C. Raven, MD, MPH, MSc

22 The SoonerCare Health Management Program 371
Carolyn J. Reconnu, RN, BSN, CCM, and Mike Herndon, DO

Section 5 Practice Change

23 Introduction: practice change fellows initiatives 379
Eric A. Coleman, MD, MPH, and Nancy Whitelaw, PhD

24 Interdisciplinary care of chronically ill adults: communities of care for people living with congestiveheart failure in the rural setting 383
Lee Greer, MD, MBA

25 Collaborative care treatment of late-life depression: development of a depression support service391
Eran D. Metzger, MD

26 Geriatric Telemedicine: supporting interdisciplinary care 407
Daniel A. Reece, MSW, LCSW

27 Integrated Patient-Centered Care: the I-PiCC pilot 417
Karyn Rizzo, RN, CHPN, GCNS

Section 6 Medicare Managed Care

28 Longitudinal care management: High risk care management 431
Chandra L. Torgerson, RN, BSN, MS, and Lynda Hedstrom, MSN, APRN, NP-C

Section 7 International Care Coordination

29 The experiences in the Republic of Korea 441
Weon-seob Yoo, PhD, MPH, MD, and Joo-bong Park Oh, MN, MS, PsyD, RN

Index 451

About the Author

Cheryl Schraeder, RN, Ph.D., FAAN is currently ClinicalAssociate Professor and also Director of Policy andPractice Initiatives, Institute for Healthcare Innovation, at theCollege of Nursing at the University of Illinois in Chicago,IL. Dr. Schraeder has been the project director/ principleinvestigator for governmental health care agencies and privatefoundation demonstrations and projects with vulnerable populations. Paul S. Shelton, EdD is currently Senior ResearchSpecialist at the Institute for Healthcare Innovation at theCollege of Nursing at the University of Illinois in Chicago, IL.Dr. Shelton has extensive experience in working with governmentalhealth care agencies and private foundations in primary caremanagement demonstrations.