reports

Comprehensive care coordination for chronically ill adults

Chapter 5: Intervention components. In: Schraeder C, Shelton PS, ed. Chichester, UK: Wiley-Blackwell:87-126.

Care coordination seeks to bridge the gap between the needs of people with complex chronic health management issues and the health system’s fragmented mix of multiple sectors and providers. Comprehensive care coordination is a patient/family system approach that puts the patient and family at the center or the care coordination team. The focus of the patient/family centered care coordination team is to decrease fragmentation or care with the ultimate goal of decreasing the need for and the cost of health care . This is accomplished by assisting patients and families in self-managing their chronic disease(s) and related psychosocial problems (Bodenheimer & Berry-Millett 2009). The goals of care coordination include improving patients ‘ functional health status and outcomes, improving self-management abilities and healthy lifestyle practices, enhancing the coordination and continuity of care, eliminating the duplication of services, and reducing the need for expensive medical services. Employing registered nurses (RNs) as the care coordinators on the care coordination team helps to accomplish these goals. The team includes the patient/family unit, the patient’s primary care provider, the nurse care coordinator, and ancillary or support persons involved in the day-to-day care management of the patient. Together the team works to identity and address the patient’s full range of needs, monitor and improve the person’s health status and self-management abilities, and decreases the need for and the fragmentation of health care.