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Comprehensive Care Coordination for Chronically Ill Adults

Cheryl Schraeder (Editor), Paul S. Shelton (Editor)
ISBN: 978-0-8138-1194-9
488 pages
October 2011, Wiley-Blackwell
Comprehensive Care Coordination for Chronically Ill Adults (0813811945) cover image


Breakthroughs in medical science and technology, combined with shifts in lifestyle and demographics, have resulted in a rapid rise in the number of individuals living with one or more chronic illnesses.  Comprehensive Care Coordination for Chronically Ill Adults presents thorough demographics on this growing sector, describes models for change, reviews current literature and examines various outcomes.

Comprehensive Care Coordination for Chronically Ill Adults is divided into two parts.  The first provides thorough discussion and background on theoretical concepts of care, including a complete profile of current demographics and chapters on current models of care, intervention components, evaluation methods, health information technology, financing, and educating an interdisciplinary team.  The second part of the book uses multiple case studies from various settings to illustrate successful comprehensive care coordination in practice.  Nurse, physician and social work leaders in community health, primary care, education and research, and health policy makers will find this book essential among resources to improve care for the chronically ill.

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Table of Contents


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


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


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


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


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

18 The Aetna Integrated Care Management Model: a managed Medicaid
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


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


28 Longitudinal care management: High risk care management
Chandra L. Torgerson, RN, BSN, MS, and Lynda Hedstrom, MSN,


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


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Author Information

Cheryl Schraeder, RN, Ph.D., FAAN is currently Clinical Associate Professor and also Director of Policy and Practice Initiatives, Institute for Healthcare Innovation, at the College of Nursing at the University of Illinois in Chicago, IL.  Dr. Schraeder has been the project director/ principle investigator for governmental health care agencies and private foundation demonstrations and projects with vulnerable populations.

Paul S. Shelton, EdD is currently Senior Research Specialist at the Institute for Healthcare Innovation at the College of Nursing at the University of Illinois in Chicago, IL. Dr. Shelton has extensive experience in working with governmental health care agencies and private foundations in primary care management demonstrations.

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The Wiley Advantage

  • Presents comprehensive care coordination within the context of current demographics and policy
  • Discuses promising practices in multiple models of care
  • Includes key information on roles within the interdisciplinary team
  • Illustrates successful comprehensive care coordination in practice with multiple case studies from various settings
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