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Editors and Contributors ix Acknowledgments xv Introduction xvii PART 1 THEORETICAL CONCEPTS 1 Chronic illness 3Paul Shelton, EdD, Cheryl Schraeder, RN, PhD, FAAN, Michael K. Berkes, BS, MSW Candidate, and Benjamin Ronk, BA 2 Overview 25Cheryl 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 39Randall S. Brown, PhD, Arkadipta Ghosh, PhD, Cheryl Schraeder, RN, PhD, FAAN, and Paul Shelton, EdD 4 Promising practices in integrated care 65Patricia J. Volland, MSW, MBA, and Mary E. Wright 5 Intervention components 87Cheryl 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 127Robert Newcomer, PhD, and L. Gail Dobell, PhD 7 Health information technology 141David A. Dorr, MD, MS and Molly M. King, BA 8 Financing and payment 167Julianne R. Howell, PhD, Robert Berenson, MD, and Patricia J. Volland, MSW, MBA 9 Education of the interdisciplinary team 191Emma 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 209Chad Boult, MD, MPH, MBA, Carol Groves, RN, MPA, and Tracy Novak, MHS 11 Care management plus 221Cherie P. Brunker, MD, David A. Dorr, MD, MS, and Adam B. Wilcox, PhD 12 Medicare coordinated care 229Angela 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 263Susan Rosenbek, RN, MS, and Eric A. Coleman, MD, MPH 14 Enhanced Discharge Planning Program at Rush University Medical Center 277Anthony 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 293Kyle 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) 303Brenda Sulick, PhD, and Christine van Reenen, PhD SECTION 4 MEDICAID MODELS 17 Introduction to Medicaid care management 317Allison Hamblin, MSPH, and Stephen A. Somers, PhD 18 The Aetna Integrated Care Management Model: a managed Medicaid paradigm 325Robert 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 339Daniel 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 349Beverly 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 361Maria C. Raven, MD, MPH, MSc 22 The SoonerCare Health Management Program 371Carolyn J. Reconnu, RN, BSN, CCM, and Mike Herndon, DO SECTION 5 PRACTICE CHANGE 23 Introduction: practice change fellows initiatives 379Eric 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 383Lee Greer, MD, MBA 25 Collaborative care treatment of late–life depression: development of a depression support service 391Eran D. Metzger, MD 26 Geriatric Telemedicine: supporting interdisciplinary care 407Daniel A. Reece, MSW, LCSW 27 Integrated Patient–Centered Care: the I–PiCC pilot 417Karyn Rizzo, RN, CHPN, GCNS SECTION 6 MEDICARE MANAGED CARE 28 Longitudinal care management: High risk care management 431Chandra 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 441Weon–seob Yoo, PhD, MPH, MD, and Joo–bong Park Oh, MN, MS, PsyD, RN Index 451