Cormorbidity
Care Models: Integrated Action Plans for Complex
Healthcare Needs
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Individuals with
comorbidity — the presence of more than one disease or health
condition at a given time — comprise more than a quarter of
the population and account for 65 cents of every U.S. healthcare
dollar. When comorbidity is complicated by advanced age and/or the
presence of behavioral health conditions, healthcare costs and care
challenges can increase exponentially.
Comorbidity Care
Models: Integrated Action Plans for Complex Healthcare Needs
presents emerging models of care for comorbidity, with a special focus
on the needs of aging multi-morbid patients as well as those whose
comorbidity encompasses physical and behavioral health conditions.
In this 38-page special
report, two industry thought leaders share programs aimed at the
co-morbid patient. Chad Boult, M.D., M.P.H.,
M.B.A., professor of public health, medicine & nursing and
director of the Lipitz Center for Integrated Health Care, Johns Hopkins
Bloomberg School of Public Health, presents Guided Care, an emerging
model of care for older multi-morbid patients that is demonstrating
early success in improving quality of life and efficiency of healthcare
utilization for this population.
The Guided Care model,
which has been in development at Johns Hopkins for several years,
depends largely on a Guided Care Nurse (GCN) who collaborates with
multiple primary care physicians to provide cost-effective care to
their chronically ill patients.
Dr. Boult reviews Guided
Care Nurse (GCN) roles and responsibilities and offers preliminary
results from initial pilots, including the impact of Guided Care on
healthcare quality and costs for 904 older patients in the
Baltimore-Washington, D.C., area.
Providing perspectives
from the Medicaid population, where there is significant behavioral
health comorbidity, is Jim Hardy, senior vice
president of care management services with McKesson Health Solutions.
Hardy describes the growing trend toward closing physical and
behavioral healthcare gaps for this population and adopting an
integrated, whole-person approach.
These integrated
approaches can help reduce the cost of chronic care, which consumes a
significant portion of state Medicaid budgets already strained by
budget cuts and the failing economy. Also at issue are large numbers of
prescriptions for Medicaid beneficiaries written by non-psychiatrists
for significant behavioral health issues, a consequence of a lack of
care coordination for these individuals.
Hardy offers strategies
for overcoming information and care gaps on both the physical and
behavioral health sides and describes initiatives underway in Illinois
and elsewhere that target the comorbid Medicaid patient, with special
attention to behavioral health comorbidity.
This special report also
provides details on:
- The real costs of
implementing the Guided Care model;
- The eight key
responsibilities of the GCN;
- EHR support for Guided
Care patient action plan, care reminders, prescription decision
support, and more;
- Strategies to empower
and motivate the older patient and move them toward self-management;
- Preliminary impact of
Guided Care on utilization, quality and efficiency of healthcare for
high-risk patients with multi-morbidity;
- Enhanced primary care
case management efforts that encompass behavioral health;
- Improvement of
information transfer and care coordination across physical and
behavioral health systems;
- Early efforts in
multidisciplinary approaches in California, Illinois and Pennsylvania;
and much more, including 10 pages of
Q&A on related issues.
Table of Contents
- Guided Care: Empowering
the Older Multi-Morbid Patient
- The Cost of
Caring
for Multiple Morbidities
- A Nurse-Guided
Model of Care
- Monitoring the
Patient Action Plan
- Smoothing Care
Transitions
- The Role of
Caregivers in Guided Care
- Using
Predictive
Modeling to Determine Eligibility
- Highlights from
Ongoing Pilot
- Patient
Assessment
of Chronic Illness Care
- The Cost of
Guided
Care
- Preliminary
Conclusions
- Coordinating Physical
and Behavioral Health Comorbidity
- Behavioral
Health
Issues in the Chronically Ill
- Challenges of
Integrating Physical and Behavioral Health
- Illinois Effort
Focuses on Medication Adherence
- Other Enhanced
Primary Care Initiatives
- Q&A: Ask the
Experts
- Measuring
Impact of
Care Improvement
- Selecting
Participants for Illinois Medical Home
- Measuring
Medication Compliance
- Measuring
Impact of
Care Improvement
- Overcoming
Patient
Resistance
- The Transient
Nature of the Medicaid Patient
- Paying the
Guided
Care Nurses
- Identifying
Members
for Case Management
- Overcoming
Resistance to Change
- Licensing and
Billing for Home Visits
- Discharge
Planning
Strategies
- Home Visit
Details
- Included
Diagnoses
- Skills and
Training
for Guided Care Nurses
- Overcoming
Patient
Resistance
- Bringing PCPs
on
Board for Behavioral Health
- Empowering the
Older Multi-Morbid Patient
- Assessing the
Impact of Guided Care
- Glossary
- For More Information
- About the Authors
Publication Date:
March 2009
Number of Pages: 38
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