Comorbidity Care Models: Integrated Action Plans for Complex Healthcare Needs

  • ID: 835673
  • Report
  • 38 Pages
  • Healthcare Intelligence Network
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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.
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- 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
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