Care Coordination for Seniors with Multiple Chronic Diseases-.ppt

Schneider Institute for Health Policy, The Heller School for Social Policy and Management, Brandeis University Care Coordination for Seniors with Multiple Chronic Diseases- Examining the Macro and Micro Level Relationships and Outcomes Marian Ryan, RRT, MPH, CHES Schneider Institute for Health Policy, The Heller School for Social Policy and Management, Brandeis University Improving Quality Via Care Coordination IOM Report makes an appeal for the redesign of our system of care to improve care coordination. Critical for Medicare beneficiaries More than half have two or more chronic conditions One fourth have mental function or cognitive impairments More than one fourth report health as fair or poor 43% report no help from doctor in coordinating their medical services (RWJ, 2001) Literature Gap: The Chronic Care Model Community Resources Policies Organization of Health Care Health System Self-Mgmt Support Delivery System Design Decision Support Clinical Information Systems Functional and Clinical Outcomes Productive Interactions Prepared PCP Active Patient -Wagner, 1992 Prepared PCP Active Patient Outcomes and Adherence Relational Coordination Communication Frequent Timely Accurate Problem solving Relationships Shared goals Shared knowledge Mutual respect Trust Productive Interactions -Gittell, 2002 -Levin Cross, 2004 Research Questions Does the Chronic Care Model improve quality outcomes and patient adherence for seniors with multiple chronic diseases? Does PCP care coordination improve outcomes and adherence to treatment? Does Relational Coordination and trust between the patient and primary care physician improve outcomes and adherence to treatment? Does Relational Coordination and trust mediate the impact of the Chronic Care Model on outcomes and adherence? Study Population Patients 65 yrs of age and older with two or more chronic conditions served by large IPA in Southern CA One of which must be diabetes (high prevalence/cost) Exclusions: