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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 Medicaid clients 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 for complex 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 congestive heart failure in the rural setting 383
Lee Greer, MD, MBA
 
25 Collaborative care treatment of late-life depression: development of a depression support service 391
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

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