Effects of Care Coordination on Hospitalization, Quality of Care, and Health Care Expenditures Among Medicare Beneficiaries
JAMAPublished 10 February 2009
Deborah Peikes, Arnold Chen, Jennifer Schore, Randall Brown
Citations764
SJR quartileQ1
SJR score5.35
SNIP10.71
Generate an AI Snapshot to get a quick, structured summary of this paper.
Study Snapshot
ObjectiveStudy objective
MethodsResearch methodology
PopulationPopulation studied
Sample sizeSample sizes
OutcomesStudy outcomes here
ResultsStudy results comes here
LimitationsResearch study limitations comes here
A concise AI-generated summary of the paper will appear here once you click Generate AI Snapshot.
TL;DR
Viable care coordination programs without a strong transitional care component are unlikely to yield net Medicare savings and programs with substantial in-person contact that target moderate to severe patients can be cost-neutral and improve some aspects of care.
Abstract
clinicaltrials.gov Identifier: NCT00627029.
Keywords
MedicineHealth ProfessionsEconomics, Econometrics and Finance
BMJCrossing the Quality Chasm: A New Health System for the 21st Century
10,744 Citations2001Alexi Baker
Analyzing health care organizations as complex systems, Crossing the Quality Chasm also documents the causes of the quality gap, identifies current practices that impede quality care, and explores how systems approaches can be used to implement change.
Journal of Consulting and Clinical PsychologyStages and processes of self-change of smoking: Toward an integrative model of change.
8,667 Citations1983James O. Prochaska, Carlo C. DiClemente
PubMedEffective physician-patient communication and health outcomes: a review.
4,076 Citations1995Moira Stewart
The quality of communication both in the history-taking segment of the visit and during discussion of the management plan was found to influence patient health outcomes.
JAMAPatient Self-management of Chronic Disease in Primary Care
3,593 Citations2002Thomas Bodenheimer
Self-management education complements traditional patient education in supporting patients to live the best possible quality of life with their chronic condition, and may soon become an integral part of high-quality primary care.
New England Journal of MedicineA Multidisciplinary Intervention to Prevent the Readmission of Elderly Patients with Congestive Heart Failure
2,336 Citations1995Michael W. Rich, Valerie Beckham +4 more
A nurse-directed, multidisciplinary intervention can improve quality of life and reduce hospital use and medical costs for elderly patients with congestive heart failure.
Medical CareEvidence Suggesting That a Chronic Disease Self-Management Program Can Improve Health Status While Reducing Hospitalization
2,245 Citations1999Kate Lorig, David S. Sobel +7 more
An intervention designed specifically to meet the needs of a heterogeneous group of chronic disease patients, including those with comorbid conditions, was feasible and beneficial beyond usual care in terms of improved health behaviors and health status.
Archives of Internal MedicineThe Care Transitions Intervention
1,874 Citations2006Eric A. Coleman, Carla Parry +2 more
Coaching chronically ill older patients and their caregivers to ensure that their needs are met during care transitions may reduce the rates of subsequent rehospitalization.
JAMAComprehensive Discharge Planning and Home Follow-up of Hospitalized Elders
1,766 Citations1999Mary D. Naylor, Dorothy Brooten +5 more
An advanced practice nurse-centered discharge planning and home care intervention for at-risk hospitalized elders reduced readmissions, lengthened the time between discharge and readmission, and decreased the costs of providing health care.
Journal of the American Geriatrics SocietyTransitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial
1,363 Citations2004Mary D. Naylor, D Brooten +4 more
Examination of the effectiveness of a transitional care intervention delivered by advanced practice nurses to elders hospitalized with heart failure to see if it improves the quality of life for these elders.
Journal of the American College of CardiologyMultidisciplinary strategies for the management of heart failure patients at high risk for admission
1,269 Citations2004Finlay A. McAlister, Simon Stewart +2 more
Multidisciplinary strategies for the management of patients with HF reduce HF hospitalizations and those programs that involve specialized follow-up by a multidisciplinary team also reduce mortality and all-cause hospitalizations.
Annals of Internal MedicineMeta-Analysis: Secondary Prevention Programs for Patients with Coronary Artery Disease
987 Citations2005Alexander M. Clark, Lisa Hartling +2 more
A systematic review to update earlier work and to determine the effects of different types of secondary prevention programs (particularly those with a structured exercise component versus those without) on mortality, MI, or hospitalization rates in patients with established CAD.
New England Journal of MedicineCoordinating Care — A Perilous Journey through the Health Care System
977 Citations2008Thomas Bodenheimer
The quality of the coordination of care is assessed, barriers to coordinated care are described, and some solutions to improve care coordination in the United States are discussed.
Annals of Internal MedicineLost in Transition: Challenges and Opportunities for Improving the Quality of Transitional Care
708 Citations2004Eric A. Coleman, Robert A. Berenson
It is shown that patients and their caregivers are unprepared for their role in the next care setting, do not understand essential steps in the management of their condition, and cannot contact appropriate health care practitioners for guidance.
American Heart JournalMedication nonadherence is associated with a broad range of adverse outcomes in patients with coronary artery disease
586 Citations2008P. Michael Ho, David J. Magid +6 more
Nonadherence to cardioprotective medications is common in clinical practice and associated with a broad range of adverse outcomes, and should be a target for quality improvement interventions to maximize the outcomes of patients with CAD.
American Journal of Preventive MedicineMotivational interviewing in health care settings Opportunities and limitations
571 Citations2001Karen M. Emmons
An overview of important issues to consider in adapting an effective counseling strategy to new settings is provided, and is intended to begin a dialogue about the use of MI in community health care settings.
CirculationDischarge Education Improves Clinical Outcomes in Patients With Chronic Heart Failure
571 Citations2005Todd M. Koelling, Monica L. Johnson +2 more
The addition of a 1-hour, nurse educator–delivered teaching session at the time of hospital discharge resulted in improved clinical outcomes, increased self-care measure adherence, and reduced cost of care in patients with systolic heart failure.
JAMAChange in the Quality of Care Delivered to Medicare Beneficiaries, 1998-1999 to 2000-2001
550 Citations2003Stephen F. Jencks, Edwin D. Huff +1 more
Care for Medicare fee-for-service plan beneficiaries improved substantially between 1998-1999 and 2000-2001, but a much larger opportunity remains for further improvement.
New England Journal of MedicineWho Is at Greatest Risk for Receiving Poor-Quality Health Care?
516 Citations2006Steven M. Asch, Eve A. Kerr +5 more
Differences among sociodemographic subgroups in the observed quality of health care are small in comparison with the gap for each subgroup between observed and desirable quality ofhealth care.
New England Journal of MedicineCare Patterns in Medicare and Their Implications for Pay for Performance
509 Citations2007Hoangmai H. Pham, Deborah Schrag +3 more
In fee-for-service Medicare, the dispersion of patients' care among multiple physicians will limit the effectiveness of pay- for-performance initiatives that rely on a single retrospective method of assigning responsibility for patient care.
Journal of Allergy and Clinical ImmunologyRelationship between adherence to inhaled corticosteroids and poor outcomes among adults with asthma
483 Citations2004L. Keoki Williams, Manel Pladevall +6 more
Adherence to ICS is poor among adult patients with asthma and is correlated with several poor asthma-related outcomes, and less than perfect adherence appears to account for the majority of asthma- related hospitalizations.
Mayo Clinic ProceedingsPatients' Understanding of Their Treatment Plans and Diagnosis at Discharge
442 Citations2005Amgad N. Makaryus, Eli A. Friedman
Lacking awareness of these factors affects a patient's ability to comply fully with discharge treatment plans and whether lack of communication between physician and patient is actually the cause of patient unawareness of discharge Instructions or if this even affects patient outcome requires further study.
JAMAPatient-Physician Communication About Out-of-Pocket Costs
415 Citations2003G. Caleb Alexander
Both patients and physicians believed that discussions of out-of-pocket costs were important, yet these discussions occurred infrequently, and further research should identify the prevalence of this problem in broader populations, investigate its causes, and evaluate the impact of enhanced communication about out- of- pocket costs on patient satisfaction, utilization of care, and outcomes.
Archives of Internal MedicineAcute Precipitants of Congestive Heart Failure Exacerbations
337 Citations2001Ross T. Tsuyuki, Robert S. McKelvie +9 more
A variety of factors, many of which are avoidable, are associated with exacerbation of CHF.
Health AffairsThe Rise In Spending Among Medicare Beneficiaries: The Role Of Chronic Disease Prevalence And Changes In Treatment Intensity
262 Citations2006Kenneth E. Thorpe, David H. Howard
Using the metabolic syndrome as a case study, it is found that the share of patients treated with medications has increased 11.5 percentage points in less than ten years, raising important questions about the "fit" of how Medicare pays for services for complex medical management.
BMJImpact of case management (Evercare) on frail elderly patients: controlled before and after analysis of quantitative outcome data
254 Citations2006Hugh Gravelle, Mark Dusheiko +6 more
Case management of frail elderly people introduced an additional range of services into primary care without an associated reduction in hospital admissions, suggesting this policy is unlikely to reduce hospital admissions.
CirculationLong-Term Healthcare and Cost Outcomes of Disease Management in a Large, Randomized, Community-Based Population With Heart Failure
236 Citations2004Autumn Dawn Galbreath, Richard A. Krasuski +5 more
Participation in DM resulted in a significant survival benefit, most notably in symptomatic systolic HF patients, and was associated with improved NYHA class, 6-minute walk test results did not improve.
The Diabetes EducatorThe Relationship Between Health Literacy and Diabetes Knowledge and Readiness to Take Health Actions
230 Citations2007Caroline Powell, Elizabeth G. Hill +1 more
While low health literacy was significantly associated with worse glycemic control and poorer disease knowledge in patients with type 2 diabetes, there was no significant relationship with their readiness to take action in disease management.
PubMedEvidence for the effect of disease management: is $1 billion a year a good investment?
216 Citations2007Soeren Mattke, Michael Seid +1 more
Although disease management seems to improve quality of care, its effect on cost is uncertain and Payers and policy makers should remain skeptical about vendor claims and demand supporting evidence based on transparent and scientifically sound methods.
Annals of Internal MedicineCare Management for Low-Risk Patients with Heart Failure
215 Citations2004Robert F. DeBusk, Nancy Houston Miller +7 more
Nurse care management for heart failure in a low-risk population of patients selected from several medical centers in the same large health maintenance organization (HMO) is evaluated.
Diabetes CareDoes Diabetes Disease Management Save Money and Improve Outcomes?
207 Citations2002Jaan Sidorov, Robert D. Shull +4 more
In this HMO, an opt-in disease management program appeared to be associated with a significant reduction in health care costs and other measures of health care use and a simultaneous improvement in HEDIS measures of quality care.
Annals of Internal MedicineCoordinating Care across Diseases, Settings, and Clinicians: A Key Role for the Generalist in Practice
193 Citations2005Christopher J. Stille, Anthony Jerant +3 more
The goal of coordination of medical care is to support patients and their families in their efforts to receive effective health care from an increasingly complex health care system.
PubMedBabel babble: physicians' use of unclarified medical jargon with patients.
176 Citations2007Cesar M. Castro, Clifford Wilson +2 more
Physicians caring for patients with limited health literacy employ unclarified jargon during key clinical functions, particularly when making recommendations and providing health education.
PubMedReturn on investment in disease management: a review.
171 Citations2005Ron Z. Goetzel, Ronald J. Ozminkowski +2 more
The results of 44 studies investigating financial impact and return on investment from disease management programs for asthma, congestive heart failure, diabetes, depression, and multiple illnesses were examined.
Mayo Clinic ProceedingsMedication Use Among Inner-City Patients After Hospital Discharge: Patient-Reported Barriers and Solutions
148 Citations2008Sunil Kripalani, Laura E. Henderson +2 more
Interventions that reduce medication costs, facilitate transportation, improve medication counseling, and supply such organizing aids as pillboxes might be beneficial in inner-city patients after hospital discharge.
Canadian Journal of Public HealthHospitalization for Ambulatory Care-Sensitive Conditions: A Method for Comparative Access and Quality Studies Using Routinely Collected Statistics
139 Citations2001Adalsteinn Brown, Michael J Goldacre +5 more
Canadian physicians following different consensus techniques selected conditions for which the relative risk of hospitalization is inversely related to ambulatory care access, and these conditions strongly overlap with lists developed for similar purposes in the U.S. and England.
PubMedReducing emergency visits in older adults with chronic illness. A randomized, controlled trial of group visits.
138 Citations2001Eric A. Coleman, Theresa B. Eilertsen +4 more
Monthly group visits with a primary care physician, nurse, and pharmacist reduce emergency department utilization for chronically ill older adults.
Journal of Health Services Research & PolicyConditions for Which Onset or Hospital Admission is Potentially Preventable by Timely and Effective Ambulatory Care
126 Citations2000Colin Sanderson, Jennifer Dixon
A consensus-based list of common conditions likely to be ambulatory care sensitive (ACS) conditions cannot be definitive, but the clear view of the panels was that the scope for avoiding admission through better ambulanceatory care is very substantial.
Medical CareCan A Disease Self-Management Program Reduce Health Care Costs?
101 Citations2003John R.C. Wheeler
A heart disease self-management program can reduce health care utilization and potentially yield monetary benefits to a health plan and compare potential cost savings with the cost of delivering the program.
Health AffairsEffectiveness Of A Disease Management Program For Patients With Diabetes
92 Citations2004Victor G. Villagra, Tamim Ahmed
Analysis of the first-year results of a multistate DDMP for people with diabetes sponsored by a national managed care organization found quality scores in the DDMP sites were significantly better than in sites without the program.
Mayo Clinic ProceedingsFunctional Health Literacy and Understanding of Medications at Discharge
89 Citations2008Michael J. Maniaci, Michael G. Heckman +1 more
It is found that patients had limited knowledge about their medications after discharge from an internal medicine residency service, with age but not years of education significantly associated with level of knowledge.
Archives of Internal MedicineUnsaid but Not Forgotten
85 Citations2001Robert A. Bell, Richard L. Kravitz +3 more
Patients' unvoiced needs affect patients' and physicians' visit evaluations and patients' subjective perceptions of improvement, and implications for clinical practice are examined.
Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Vol. 1: Series Overview and Methodology
80 Citations2004Kaveh G Shojania, Kathryn M McDonald +2 more
Disease ManagementGuided Care: Cost and Utilization Outcomes in a Pilot Study
73 Citations2008Martha L. Sylvia, Michael Griswold +4 more
It is suggested that GC may reduce insurance expenditures for high-risk older adults, and may help to increase the efficiency of health care for the aging American population.
PubMedDisease management produces limited quality-of-life improvements in patients with congestive heart failure: evidence from a randomized trial in community-dwelling patients.
70 Citations2005Brad Smith, Emma Forkner +7 more
It is unclear whether disease management can provide long-term improvement in HRQL for patients with congestive heart failure, as no effect of disease management was observed across any of the SF-36 components.
Australian and New Zealand Journal of MedicineUncovering a multitude of sins: medication management in the home post acute hospitalisation among the chronically ill
60 Citations1999Simon Stewart, Sue Pearson
Assessment of medication management in the home provides an invaluable opportunity to detect and address problems likely to result in poorer health outcomes.
Mathematica Policy Research ReportsThe Evaluation of the Medicare Coordinated Care Demonstration: Findings for the First Two Years
35 Citations2007Randall Brown, Deborah Peikes +4 more
Findings indicate that patients and physicians were generally very satisfied with the Medicare Coordinated Care Demonstration, but few programs had statistically detectable effects on patients’ behavior or use of Medicare services.
American Heart JournalThe Heart Failure Adherence and Retention Trial (HART): Design and rationale
34 Citations2008Lynda H. Powell, James E. Calvin +8 more
The HART trial evaluated the benefit of patient self-management skills training in combination with HF education, over HF education alone, on the composite end points of death/HF hospitalizations and death/all-cause hospitalizations in patients with mild to moderate systolic or diastolic dysfunction.
Congestive Heart FailureImpact of Provider Self‐Management Education, Patient Self‐Efficacy, and Health Status on Patient Adherence in Heart Failure in a Veterans Administration Population
31 Citations2008Usha Subramanian, Faith Hopp +2 more
Surveys completed by HF patients receiving care at 2 Veterans Affairs hospitals in 2003 suggest that provider interventions may lead to improved adherence with HF self-management and thus improvements in patients' health.
Issue Lab (Candid)Quality of Health Care for Medicare Beneficiaries: A Chartbook
23 Citations2005Douglas McCarthy, Sheila Leatherman
Southern Medical JournalAmbulatory Care-sensitive Conditions: Clinical Outcomes and Impact on Intensive Care Unit Resource Use
15 Citations2003John G. Burr, Glenda Sherman +4 more
Interventions aimed at preventing potentially preventable ICU admissions in patients with ambulatory care-sensitive conditions are suggested, which would improve ICU bed use.