The transitional care and comprehensive care coordination debate

Which approach works best for people with chronic illness? We provide some models (and a real-life story) for study.Advances in medical science and technology, accompanied by the graying of America, mean tremendous growth in the number of individuals living with chronic illnesses. Approximately 80 percent of Americans ages 50 and older have at least one chronic condition (Anderson, 2010). They present significant challenges to our healthcare delivery system, which provides questionable quality of care to this population.A majority of these chronically ill people are publicly insured through either Medicare or Medicaid, and have combinations of complex, interacting medical and mental health conditions, as well as functional or physical limitations. Though a small percentage of total Medicare and Medicaid beneficiaries is comprised of the chronically ill, it accounts for a majority of expenditures. The majority of beneficiaries covered by both Medicare and Medicaid (dual eligibles) who have one or more chronic conditions and functional limitations have annual expenditures that are typically in the ninety-fifth percentile (The Lewin Group, 2010). The high cost of healthcare for the chronically ill can be attributed to several factors, including poor medication adherence, deficient self-care skills, low health literacy, lack of access to primary care, psychosocial issues, and communication and coordination gaps across multiple healthcare providers (Brown, 2009; Hamblin and Somers, 2011).The Patient Protection and Affordable Care Act (ACA) legislation lays the foundation for potential changes in healthcare delivery and financing. Many of the ACA's provisions address individuals with chronic illness, and are focused on improvements in how services are delivered, including payment reimbursement, public health expansion (home- and community-based services), and care coordination (Shugarman and Whitenhill, 2011). The legislation contains delivery models, such as accountable care organizations (ACO), medical homes, health homes, and transitional care interventions, that offer incentives to providers for improving care for chronically ill populations.This article presents an overview of the emerging research evidence on two new approaches to primary care for the chronically ill, patient populations that benefit from their different perspectives and approaches to care, and a case study that highlights the need for integrated, comprehensive care coordination.Two Approaches to Primary Care for the Chronically IllDuring the past two decades, a number of healthcare professionals and researchers have developed and tested new models of primary care for patients with chronic illness. Two leading approaches are transitional care and comprehensive care coordination. Both models target similar at-risk, vulnerable chronically ill adults, and focus on reducing avoidable hospitalizations and re-admissions. Methods used include performing an initial comprehensive assessment; implementing an evidence-based care management strategy and evidence-based coaching and self-care education approach; and, facilitating and coordinating appropriate medical and community-based services. The two models differ on where the intervention is initiated, intervention staffing, and intervention duration.Both approaches seek to improve health outcomes as well as the patient's quality of life and satisfaction with care. They have demonstrated success with improving care processes, quality of life, and satisfaction with care, but have shown limited success in reducing total healthcare costs, which is commonly what the broader healthcare system seeks. However, the results suggest that certain of the models' components are potentially cost-effective when included in comprehensive efforts to manage the healthcare needs of adults with multiple chronic conditions. Enhancing the effectiveness of either of the two approaches depends upon appropriate targeting of those patients whose healthcare profile makes them better suited for one over the other. …