Comprehensive Care Coordination for Chronically Ill Adults

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

2 Overview
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
Randall S. Brown, PhD, Arkadipta Ghosh, PhD, Cheryl Schraeder, RN,
PhD, FAAN, and Paul Shelton, EdD

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

5 Intervention components
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
Robert Newcomer, PhD, and L. Gail Dobell, PhD

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

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

9 Education of the interdisciplinary team
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
Chad Boult, MD, MPH, MBA, Carol Groves, RN, MPA, and
Tracy Novak, MHS

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

12 Medicare coordinated care
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
Susan Rosenbek, RN, MS, and Eric A. Coleman, MD, MPH

14 Enhanced Discharge Planning Program at Rush University
Medical Center
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
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)
Brenda Sulick, PhD, and Christine van Reenen, PhD
\

SECTION 4 MEDICAID MODELS

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

18 The Aetna Integrated Care Management Model: a managed Medicaid
paradigm
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 Medicaid clients with co-occurring medical,
mental, and substance abuse disorders
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 for complex Medicaid clients
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
Carolyn J. Reconnu, RN, BSN, CCM, and Mike Herndon, DO

SECTION 5 PRACTICE CHANGE

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

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

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

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

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

SECTION 6 MEDICARE MANAGED CARE

28 Longitudinal care management: High risk care management
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
Weon-seob Yoo, PhD, MPH, MD, and Joo-bong Park Oh, MN, MS,
PsyD, RN