to one or more significant chronic illnesses. These programs rely on rigorous care coordination and well-managed interdisciplinary clinical management to achieve quality outcomes (Anderson, 2005; Bodenheimer, 2008).

Provisions in the Medicare Prescription Drug Improvement Modernization Act of 2003 launched a series of population-based care coordination pilot programs to test the applicability of these strategies for Medicare beneficiaries and to assess the quality improvement outcomes and cost savings that could be achieved (Anderson, 2005; Foote, 2003). The evaluations revealed that while these programs yielded a variety of important quality outcomes, cost savings remained largely elusive (Ayanian, 2009; Peikes et al., 2009). These findings echoed those in an earlier report from the Congressional Budget Office for the U.S. Senate Budget Committee that noted the promise but lack of evidence of cost savings from these programs (CBO, 2004).

Further analyses, however, revealed that cost savings—principally by reducing avoidable hospital admissions—in addition to quality outcomes have been achieved by some care management programs (Bodenheimer and Berry-Millett, 2009; Bott et al., 2009; Sochalski et al., 2009). Programs that have been successful share several important features: care management strategies directed by nurses who were integral to the physician’s practice, who coordinated care and communication between the patient and all members of the interdisciplinary team serving the patient, and who directly provided health care services via in-person and telephonic/electronic methods. Increasing evidence is showing that enhanced and integral involvement of nurses in both the coordination and delivery of care, particularly for patients enduring multiple chronic illnesses and complex care regimens, and in care management is critical to achieving cost and quality targets (Fisher et al., 2009).

Several programs and initiatives included in the health reform legislation involve interdisciplinary and cross-setting care coordination and care management services of RNs.

Patient-Centered Medical Homes (PCMH)

Health reform raised the profile of strategies seeking to eliminate fragmentation in care and its costly and poor quality consequences. A recent report from the Institute of Medicine’s Roundtable on Evidence-Based Medicine (2009) estimated potential annual savings of $271 billion that could accrue by 2014 by facilitating care coordination which would reduce these discontinuities in care. One such strategy is the patient-centered medical home, an enhanced model of primary care through which care teams attend to the multifaceted needs of patients and provide whole person comprehensive and coordinated patient-centered care (Kaye and Takach, 2009).

Health reform’s version of the PCMH is an outgrowth of both structural and care delivery innovations over the past several decades. The structure derives from the pediatric medical home model developed to mainstream care for special



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