With the growing number of older adults needing complex medical care, new models of care are needed to reduce unnecessary Medicare costs while helping older adults achieve their highest level of well-being. Advances in models for care coordination have occurred over the past 10 years, yet the research is not complete. Now is the time for nurses to examine the literature and identify research questions for future studies. This article identifies 2 research questions that will fill the gaps in the state of the science on how best to meet the needs of older adults with multiple chronic conditions.
BrownR. S., PeikesD., PetersonG., SchoreJ., & RazafindrakotoC. M. (2012). Six features of Medicare coordinated care demonstration programs that cut hospital admissions of high-risk patients. Health Affairs, 31(6), 1156–1166. http://dx.doi.org/10.1377/hlthaff.2012.0393.
4.
BuckH., MeghaniS., BettgerJ., ByunE., FachkoM., O'ConnorM., … NaylorM. (2012). The use of comorbidities among adults experiencing care transitions: a systematic review and evolutionary analysis of empirical literature. Chronic Illness, 8(4), 278–295. http://dx.doi.org/10.1177/1742395312444741.
5.
BuntinM., CollaC. & EscarceJ. (2009). Effects of payment changes on trends in post-acute care. Health Services Research, 44(4), 1188–1210.
6.
CliffordJ. (1988). Will primary nursing survive?Journal of Professional Nursing, 4(2), 77.
7.
ColemanE. A., SmithJ. D., FrankJ. C., MinS.-J., ParryC., & KramerA. M. (2004). Preparing patients and caregivers to participate in care delivered across settings: The care transitions intervention. Journal of the American Geriatrics Society, 52(11), 1817–1825. http://dx.doi.org/10.1111/j.1532-5415.2004.52504.x.
8.
DavesonB. A., HardingR., ShipmanC., MasonB. L., EpiphaniouE., HigginsonI. J., … MurrayS. (2014). The real-world problem of care coordination: A longitudinal qualitative study with patients living with advanced progressive illness and their unpaid caregivers. Plos One, 9(5), http://dx.doi.org/10.1371/journal.pone.0095523.
JencksS., & BrockJ. (2013). Hospital accountability and population health: Lessons from measuring readmission rates. Annals of Internal Medicine, 159(9), 629–631.
13.
KelleyT., & LittmanJ. (2001). The art of innovation. New York, NY: Random House.
14.
LeffB., SpragensL. H., MoranoB., PowellJ., BickertT., BondC., … SiuL. (2012). Rapid reengineering of acute medical care for Medicare beneficiaries: The Medicare innovations collaborative. Health Affairs, 31(6), 1204–1215.
15.
LochnerK. A., & CoxC. S. (2013). Prevalence of multiple chronic conditions among Medicare beneficiaries, United States, 2010. Preventing Chronic Disease, 25(10), E61. http://dx.doi.org/10.5888/pcd10.120137.
NaylorM. (2012). Advancing high quality transitional care: The central role of nursing and its leadership. Nursing Administration Quarterly, 36(2), 115–126.
18.
ReinhardS. (2011, May). Inter-professional care coordination: Looking to the future. Presented at the conference of The New York Academy of Medicine, New York, NY.
19.
ReinhardS. (2013). What do older adults want from integrated care?Generations, 3(2), 68–71.
20.
RodriguezH. P., von GlahnT., ElliottM. N., RogersW. H., & SafranD. G. (2009). The effect of performance-based financial incentives on improving patient care experiences: A statewide evaluation. Journal of General Internal Medicine, 24(12), 1281–1288.
21.
SilvermanD. (2013). Doing qualitative research. London, United Kingdom: SAGE.
22.
SloaneP. D., OudenhovenM. D., BroylesI., & McNabneyM. (2014). Challenges to cost-effective care of older adults with multiple chronic conditions: Perspectives of program of all-inclusive care for the elderly medical directors. Journal of the American Geriatrics Society, 62(3), 564–565.
23.
SmithS., AllwrightS., & O'DowdT. (2007). Effectiveness of shared care across the interface between primary and specialty care in chronic disease management. Cochrane Database of Systematic Reviews, (3), CD004910. http://dx.doi.org/10.1002/14651858.CD004910.pub2.
