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One such study [ 6] found that failures came mainly from either low support from home health agencies or insufficient coordination with patients.
For example, the PhoenixCare intervention shows that home-based case management provided by registered nurse case managers may, in coordination with patients' existing sources of medical care, improve the care of chronically, severely ill patients [ 24].
The literature shows that intensive home-based case management provided by registered nurse case managers may, in coordination with patients' existing sources of medical care, improve the realization of care of chronically severely ill patients in the last years of life [ 22].
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(3) Communication and coordination with the patient's medical home.
Many staff identified challenges in clinic coordination that interfered with patients getting the services they needed, such that many patients disappeared from clinical care: "the flow of patients, the problem is… they come but sometimes they don't turn up due to lack of counseling.
Lower plasma Se levels have been associated with decreased motor coordination among patients with Parkinson's disease (Richwine et al. 2005; Shahar et al. 2010).
11 12 These concepts are often associated with the term 'patient-centered care.' 13 The essential element of good chronic illness care is productive interaction between patients and (teams of) healthcare professionals, as opposed to interactions that tend to be frustrating when coordination among professionals and with patients is not prioritised.
We designed this study to determine the effectiveness of post-diagnosis treatment and care coordination for patients with dementia and their caregivers by memory clinics compared with care provided by general practitioners.
Themes may be utilized to design interventions and improve care coordination for patients with pediatric-onset chronic conditions.
Since its inception, just as envisioned with its creation under the Affordable Care Act, CMMI has done excellent work and has developed forward-looking models such as advanced "accountable care organizations" and models focused on improving care coordination for patients with specific conditions, such as the Oncology Care Model.
Strategies for a better coordination of patients with multiple chronic conditions are urgently needed.
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