SOCW-6111-Discussion Wk 6

  

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Discussion 1:Self-Determination

In the Christ & Diwan (2008) article, the authors list seven domains that social workers should address in order to fully assess an older client’s needs. Each domain is considered equally important. This comprehensive evaluation fits well with the social work perspective that it is important to not only address the internal concerns of clients but also their environment. Making decisions for older adults without their input occurs often. In society people sometimes treat their elders like children—making decisions for them based on what they think is best rather than from the client’s perspective. While at times this may be well intentioned, the potential for infantilism and, in turn, compromised self-determination, occurs.

For this Discussion, review the program case study for the Petrakis family. You will focus not on Helen, but on her mother-in-law, Magda. What decisions were made about Magda’s treatment without a formal assessment and/or her input? Consider how Christ & Diwan’s (2008) seven domains relate to Magda’s case. Complete an assessment for Magda and identify the choices that were made without her feedback.

· Post a summary of your assessment of Magda’s situation that addresses the seven domains.

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· Fill in the gaps in content as necessary. 

· Describe ways you would have included Magda in the original assessment and treatment plan. 

· Include questions you would have asked Magda and her professional support system (doctors, nurses, etc.) to gain further insight into the situation.

References (use 2 or more)

Christ, G., & Diwan, S. (2008). Chronic illness and aging: The role of social work in managing chronic illness care. Council on social work education. Retrieved from http://www.cswe.org/getattachment/Centers-Initiatives/CSWE-Gero-Ed-Center/Teaching-Tools/Gero-Competencies/Practice-Guides/Assignments-Measurments/CI-Sec2-Role-SW .aspx

Paveza, G. J. (2013). Assessment of the elderly. In M. J. Holosko, C. N. Dulmus, & K. M. Sowers (Eds.), Social work practice with individuals and families: Evidence-informed assessments and interventions (pp. 177–195). Hoboken, NJ: Wiley.

Plummer, S.-B., Makris, S., & Brocksen, S. M. (Eds.). (2014a). Sessions: case histories. Baltimore, MD: Laureate International Universities Publishing. [Vital Source e-reader].

  • The Petrakis      Family (pp. 20–22)

Discussion 2: Elder Abuse

Each year on or around June 15, communities and municipalities around the world plan activities and programs to recognize World Elder Abuse Awareness Day, a day set aside to spread awareness of the abuse of the elderly (Center of Excellence on Elder Abuse & Neglect, 2013). The abuse of older adults is a growing concern and statistics suggest that the number of elders experiencing abuse is an alarmingly high number. Research suggests that close to half the people diagnosed with dementia experience some form of abuse (Cooper, C., Selwood, A., Blanchard, M., Walker, Z., Blizard, R., & Livingston, G., 2009; Wiglesworth, A., Mosqueda, L., Mulnard, R., Liao, S., Gibbs, L., & Fitzgerald, W., 2010, as cited on http://www.ncea.aoa.gov/Library/Data/index.aspx). Elder abuse takes on many forms and can include physical, emotional, psychological, and economic abuse. The legendary American actor, Mickey Rooney, spoke to the United States Senate, describing his own experiences of pain and neglect at the hands of his stepson, asking legislators to take seriously the abuse of the elderly.

For this Discussion, find a scholarly article that presents some of the most salient psychosocial issues related to elder abuse.

· Post a summary of the article you found. 

· How does the article reinforce the importance of assessing potential abuse and neglect when working with the elderly?

· Describe prevention and/or intervention strategies on the micro, mezzo, and macro levels that can be used to address the issue of abuse and neglect of the elderly.

References (use 2 or more)
Paveza, G. J. (2013). Assessment of the elderly. In M. J. Holosko, C. N. Dulmus, & K. M. Sowers (Eds.), Social work practice with individuals and families: Evidence-informed assessments and interventions (pp. 177–195). Hoboken, NJ: Wiley.

Petrakis Family Episode 3

Petrakis Family Episode 3
Program Transcript

FEMALE SPEAKER: And you’re sure Alec is stealing from her? Pills. From his
own grandmother.

FEMALE SPEAKER: I can’t call the police. He’s still on probation! Possession.

FEMALE SPEAKER: Have you spoken to him about it?

FEMALE SPEAKER: He denied it. But I found them. He got her oxy prescription
refilled so he could take them himself. How old are you?

FEMALE SPEAKER: Excuse me?

FEMALE SPEAKER: I said, how old are you?

FEMALE SPEAKER: I don’t see what that has to do with anything.

FEMALE SPEAKER: You’re too damn young to be doing this job. That’s it. You
don’t know what you’re doing! None of this would have happened! It was your
bright idea! You’re the one who told me to have him move in with her and take
care of her!

FEMALE SPEAKER: I did tell you to do anything! I only suggested it. And we
talked about it together.

FEMALE SPEAKER: No, no. That’s not true. I followed your advice. You’re going
to have to fix this. You have to do something. I don’t know what else to do. I can’t
call the police. He can’t go back to jail. Awful things will happen to him. I can’t let
that happen. I won’t!

Petrakis Family Episode 3
Additional Content Attribution

MUSIC:
Music by Clean Cuts

Original Art and Photography Provided By:
Brian Kline and Nico Danks

©2013 Laureate Education, Inc. 1

1
*Grace Christ, DSW—Columbia University, School of Social Work
Sadhna Diwan, PhD—San Jose State University, School of Social Work

CHRONIC ILLNESS AND AGING

SECTION 2: THE ROLE OF SOCIAL WORK
IN MANAGING CHRONIC ILLNESS CARE

  • Grace Christ and Sadhna Diwan*
  • Synopsis
  • Managing chronic illness presents a profound challenge to the social work

     

    profession, not only because of the myriad formal and informal services required by the 
    increasing number of chronically ill elders, but also because the caregivers, too, require 
    our support and empowerment. As professionals, social workers experience first‐hand 
    the effects of the met and unmet patient needs, which brings with it a responsibility to 
    insure that practice and policy decisions give full recognition to the impact of 
    psychosocial aspects and services that provide total care to chronically ill older adults 
    and their caregivers. 

    This section describes some of the most recent literature addressing the role of 
    social workers in managing chronic illness care specifically related to conducting 
    biopsychosocial assessments, providing interventions, and in designing and 
    implementing effective models of health services delivery such as care coordination. 

    Characteristics of Chronic Illness
    as They Impact the Social Work Role

    Three important characteristics of chronic illnesses among older adults need to be considered 
    as they affect the social work role and function.  

    1. The trajectory for many serious illnesses has changed from an acute terminal 
    course to a much longer chronic period, with episodes of exacerbations and 
    remissions interspersed with extended periods of good functioning.  

    2. The trajectory of advanced chronic and terminal illnesses has changed from a 
    relatively brief period to a longer period in which both curative and 
    palliative treatments are combined. Research suggests that a long, advanced 
    chronic illness can be highly stressful for both patients and their families. 

    Christ & Diwan Chronic Illness—Role of Social Work

    3. The increase in the total number of older people with advanced chronic and 
    terminal illnesses will require more curative and palliative care being 
    provided in the home, with greater reliance on provision by family members.  

    Advances in medical care have changed the illness trajectory in ways that 
    dramatically alter the older adult’s experience of chronic illness. Facilitating and 
    enhancing positive health behaviors at all stages of life as well as effective management 
    of chronic illness is central to the social worker’s role, knowledge, value, and skill base 
    in health care.  

    The specific role of social workers in health care is to address psychological, 
    behavioral, and social factors by (1) assessing patient and family psychosocial health 
    needs, (2) providing interventions required to address their psychosocial needs and 
    promote their adaptation to illness and disability, and (3) developing and implementing 
    effective models of health services delivery. The following sections provide an overview 
    of issues related to Biopsychosocial Assessment of older persons with chronic 
    conditions; a description of the range of social work interventions relevant to the 
    management of chronic conditions; and a description of the evidence base of one model 
    of service delivery: care coordination for older persons. 

  • Psychosocial Assessment of Older Adults with Chronic Conditions
  • Because of the frequency of multiple chronic conditions in older adults, a 
    comprehensive biopsychosocial assessment of needs and resources has become the 
    most important part of service delivery and is the beginning of the intervention process 
    to address the management of chronic conditions among them. The National 
    Association of Social Workers (NASW, 2005) and the American Geriatrics Society (AGS, 
    2005) recommend a biopsychosocial approach to the assessment of older adults. This 
    section reviews the evidence supporting comprehensive geriatric assessments and, 
    using a biopsychosocial framework, describes the rationale or evidence supporting 
    seven typical domains of psychosocial assessment for social workers in the 
    management of chronic illnesses.  

    Comprehensive Assessments

    Comprehensive geriatric assessment (CGA) and geriatric evaluation and 
    management (GEMs) programs have shown positive impact on improving or 
    maintaining cognitive and physical function (Urdangarin, 2000).  

    These programs have shown increased likelihood of patients living at home, 
    decreased likelihood of hospitalization during follow‐up, and a reduction in mortality. 

    The primary component of CGA and GEM programs is an interdisciplinary 
    team consisting primarily of physicians, nurses, and social workers. 

    2

    Christ & Diwan Chronic Illness—Role of Social Work

    Comprehensive assessment and management programs for the care of older adults 
    in the health care system have been evaluated in the U.S. over the last decade and have 
    shown positive outcomes. For example, the CGA programs without follow‐up care and 
    the GEMS programs that incorporate follow‐up care and management have reported 
    favorable effects on cognitive and physical functioning, an increased likelihood of living 
    at home, a decreased likelihood of hospitalization during follow‐up, and a reduction in 
    mortality (Urdangarin, 2000). The primary component of these programs is an 
    interdisciplinary team consisting mainly of physicians, nurses, and social workers, but 
    also can include specialists from fields, such as occupational and physical therapy, 
    nutrition, pharmacy, audiology, and psychology (Agostini, Baker, & Bogardus, 2001; 
    Wieland & Hirth, 2003).  

    CGA is more effective when it is targeted to older adults with functional 
    impairments, geriatric syndromes, or high use of hospital and nursing home care. The 
    American Geriatrics Society (AGS) issued the following position statement in 2005: 
    “Comprehensive geriatric assessment has demonstrated usefulness in improving the 
    health status of frail, older patients. Therefore, elements of CGA should be incorporated 
    into the care provided to these elderly individuals”  
    (http://www.americangeriatrics.org). The degree to which those elements have an 
    impact on patients is still being evaluated, but components of CGA have already 
    become an accepted part of geriatric primary care and inpatient consultation services, 
    especially in managed health care programs.  

    Comprehensive assessment, however, is not feasible for all older persons; 
    therefore, programs have developed criteria to target individuals most likely to 
    need such assessments.  

    These criteria include people who have functional impairments in their ability to 
    perform activities of daily living (ADLs); have one or more geriatric syndromes, such as 
    falls, depression, dementia, delirium, or weight loss; or show patterns of high use of 
    hospital or nursing home placements (AGS, 2005).  

    With increasing numbers of elders with chronic illness living in the community, 
    screening and assessment has become increasingly important to the provision 
    of continuity of care to identify those with biopsychosocial needs.  

    Social workers provide health and mental health services to the elderly in a variety 
    of settings across the continuum of care (Berkman, Maramaldi, Breon, & Howe, 2002). 
    They help older people who are active and healthy, as well as those who have poor 
    health, and address the needs of the elderly who live in the community, as well as those 
    hospitalized or in long‐term care institutions. Many people are not aware of available 
    social services, and families with serious social problems are not finding the community 
    resources and services they need. Regardless of site, screening and assessment of need 

    3

    http://www.americangeriatrics.org/

    Christ & Diwan Chronic Illness—Role of Social Work

    for psychosocial help are still the most important part of service delivery and mark the 
    beginning of the intervention process (Berkman et al., 2002).  

    Process of Conducting Geriatric Assessments

    Conducting comprehensive geriatric assessments involves using general social 
    work clinical interviewing skills as well as knowledge of special conditions that may 
    apply to working with specific populations. Geron (2006) and Berkman and colleagues 
    (2002) summarize these skills and processes as: 

    Establishing rapport with the respondent 

    Explaining the purpose of assessment 

    Using observation and clinical judgment 

    Assessing the client’s preferences (Kane & Degenholtz, 1997) 

    Knowing human behavior and caregiver dynamics 

    Demonstrating cultural competency in addressing and understanding 
    diverse groups of older persons 

    For a review on the social work processes involved in conducting geriatric 
    assessments and a discussion of special issues in working with older persons, see Geron 
    (2006).  

    Biopsychosocial Framework for Seven Domains of Assessment

    The conceptual framework that supports comprehensive geriatric assessment, 
    evaluation, and management is a biopsychosocial approach to understanding 
    chronic illness care.  

    To develop a substantive understanding of an older adult’s needs and resources 
    there are seven typical domains of assessment that are important for social 
    workers.  

    1) Physical well‐being and health 
    2) Psychological well‐being and mental health 
    3) Cognitive capacity 
    4) Ability to perform basic ADLs and instrumental activities of daily living 

    (IADLs) 
    5) Social Functioning 
    6) Physical environment 
    7) Assessment of family caregivers  

    4

    Christ & Diwan Chronic Illness—Role of Social Work

    These domains of assessment along with the rationale or evidence supporting 
    specific areas of assessment are adapted from Diwan & Balaswamy, (2006) and 
    presented in Table 1.  

    5

    Christ & Diwan Chronic Illness—Role of Social Work

    6

    Table 1. Biopsychosocial Assessment Domains and Specific Areas of Assessment Related to Chronic Illness Care

    Major
    Domains of
    Assessment

    Current Evidence or Rationale Supporting

    Specific Areas of Assessment Within Each Domain

    Physical well-
    being and
    health

    The prevalence of chronic diseases increases significantly with age, with the most common health problems being arthritis,
    cardiovascular disease, cancer, and diabetes (Administration on Aging, 2007).

    Important areas of assessment are overall health status; the presence of pain; nutritional status; risk for falling; incontinence;
    sleep; alcohol and drug use; dental or oral health; sensory perception, especially vision and hearing (McInnis-Dittrich, 2004);
    and use and misuse of medications (Kane & Kane, 2000).

    These health conditions may significantly influence other domains: for example, by lowering psychological well-being, limiting
    functional ability, and diminishing quality of life.

    Psychological
    well-being and
    mental health

    Depression, anxiety, and dementia are frequently under-diagnosed in elders, in part because symptoms can be misattributed to
    health problems, and in part because of stereotypical beliefs that aging is associated with increased negative affect.

    Substance use, misuse, or abuse (particularly of alcohol, prescription drugs, and over-the-counter medications) is also under-
    diagnosed, often because decreased activity among the elderly is attributed to other age-related factors. Consequently,
    substance abuse is not seen as the cause of a disruption from work or social activities (Widlitz & Marin, 2002).

    As an indicator of mental health problems, the rate of completed suicide in the U.S. is highest among people over 65 years of
    age (DHHS, 1999)

    Cognitive
    capacity

    Two distinct types of cognitive changes occur as people age: The first is the gradual decline in memory, selective attention,
    information processing, and problem-solving ability that occurs with normal aging; the second is a progressive, irreversible,
    global deterioration in capacity that occurs as a result of illnesses or diseases such as Alzheimer’s, Huntington’s, Parkinson’s,
    and AIDS; or vascular dementia, often caused by strokes or tumors.

    As the dementia progresses, significant changes occur in memory, language, object recognition, and executive functioning: the
    ability to plan, organize, sequence, and abstract. Behavioral symptoms, such as agitation, hallucinations, and wandering also
    are common. Individuals exhibiting these behaviors require increased supervision by family members and others, which often
    causes considerable strain and burden on caregivers, both formal and informal.

    Ability to
    perform various
    ADLs

    Functional ability is measured through performance in the ADLs, which include dressing, bathing, eating, grooming, toileting,
    transferring from bed or chair, mobility, and continence; and performance in the IADLs, which include cooking, cleaning,
    shopping, money management, use of transportation, telephone, and administration of medications.

    Increasing disability in performing these activities predicts a person’s movement along the continuum of care, ranging from
    independent living to assisted living to nursing home care.

    A variety of physical, psychological, cognitive, and environmental factors influence a person’s ability to perform ADLs and
    IADLs. Therefore, an evaluation of all factors that may contribute to a person’s disability is recommended.

    Christ & Diwan Chronic Illness—Role of Social Work

    7

    Table 1 continued…

    Major
    Domains of
    Assessment
    Specific Areas of Assessment Within Each Domain

    Social
    functioning

    Social integration (having social ties, roles, and activities) is associated with better health outcomes, such as lower risk of
    mortality, cardiovascular disease, cancer mortality, and functional decline (Unger, McAvay, Bruce, Berkman, & Seeman,
    1999).

    Health also affects social functioning because people who are confined to bed or have severely impaired mobility are likely
    to disengage from social activities.

    Satisfaction with one’s social support is more strongly related to psychological well-being than are objective indicators of
    social functioning, such as frequency of social contact (Krause, 1995).

    Physical
    environment

    The risk of falling increases exponentially with age and, among older adults, falls are the leading cause of deaths caused by
    injury and are the most common cause of injuries and hospital admissions for trauma. For people ages 65 and older, two-
    thirds to one-half of falls occur in or around the home (CDC, 2006).

    Thus, assessing the fit between the older person’s capabilities and his or her home environment is an important assessment
    domain, and the prevention of falls is a critical area of intervention. Typical home assessments will examine the condition,
    adequacy, and accessibility of lighting, flooring, and carpeting, including obstacles or potential hazards for falling; bathing
    and toileting, including the need for assistive devices; kitchen; heating and cooling; access to the home from outside; access
    to rooms within the home; and personal safety issues, such as neighborhood conditions.

    Older adults may prefer to live in an environment regarded as inadequate by a professional, but one that permits them more
    freedom and social connection. Kane & Kane, (2000) suggest integrating the concept of “negotiated risk,” into the
    assessment process whereby older persons have a voice in determining their level of risk-taking,

    Assessment of
    family
    caregivers

    Approximately 66% of community-dwelling people who need long-term care rely solely on family and friends for help, and
    28% receive a combination of informal and formal care (Liu, Manton, & Aragon, 2000).

    With declining functional ability associated with chronic illness and dementia, increasing numbers of older people are in
    need of care. The need for increased vigilance puts considerable strain on caregivers, which in turn not only puts the elderly
    person at greater risk for entering a nursing home but also increases the likelihood of abuse or neglect.

    Thus, assessing both objective and subjective components of caregivers’ strain is important for gaining a better
    understanding of their needs.

    Objective components of burden refer to the disruption in finances, family life, and social relations, whereas subjective
    components refer to caregivers’ appraisal of their situation as stressful (Gaugler, Kane, & Langlois, 2000).

    ADLs: activities of daily living; IADLs: instrumental activities of daily living 

    Adapted from Diwan & Balaswamy (2006). 

    Christ & Diwan Chronic Illness—Role of Social Work

  • Biopsychosocial Needs and Services for Chronic Illness Care
  • Aging populations require diverse biopsychosocial services from both formal 
    and informal sources. 

    Biopsychosocial services are defined as those psychological, social, and health care 
    services that enable patients, their families, and health care providers to manage the 
    psychological, behavioral and social aspects of illness and its consequences and thus 
    promote better health (Institute of Medicine, 2007).  When informal support is 
    insufficient to address a patient’s needs, more formal services are needed. Table 2 lists 
    the common biopsychosocial health needs of elders with chronic illnesses together with 
    typical community‐based services that can be helpful in meeting these needs (Institute 
    of Medicine, 2007). 

     

    The evidence supporting the effectiveness of various biopsychosocial services is 
    mixed.  

    In a comprehensive review of the literature on the effectiveness of psychosocial 
    health services for patients with cancer, the Institute of Medicine (2007) notes that there 
    is generally good evidence (through meta analyses of randomized controlled trials) of 
    the effectiveness of psychotherapeutic services, especially cognitive behavioral therapy, 
    that help ameliorate emotional distress that co‐occurs with many chronic illnesses. A 
    similar level of evidence exists for behavioral interventions that help individuals 
    manage their symptoms and improve their overall health. However, many 
    interventions, such as the provision of transportation, financial assistance, and 
    medication assistance, have not been examined specifically for effectiveness but are 
    widely accepted as humanitarian services necessary to address basic needs. Many of the 
    services and studies reviewed in this report address not just cancer, but a number of 
    other chronic illnesses as well. 

    8

    Christ & Diwan Chronic Illness—Role of Social Work

    Table 2. Biopsychosocial Health Needs of Chronically Ill
    Older Adults and Evidence-Informed Services

    Biopsychosocial Health
    Needs

    Evidence Informed Services for Addressing
    Needs

    Information and education about
    illness, treatments, costs, health
    maintenance, and services
    available for patients.

    Continuous access to information and education about
    illness, treatments, and their effects, costs, health
    maintenance, and psychosocial and financial services.

    Decision-making support for patients and family who are
    considering options for treatment and care
    arrangements.

    Useful information and support through services such as
    health education classes, disease management seminars,
    and health coaches.

    Help in managing illness
    throughout its different phases:
    e.g., prevention, diagnosis,
    treatment, remissions and
    exacerbations, and advanced
    illness.

    Care coordination interventions to facilitate more
    appropriate delivery of services and assist with
    transitions in care.

    Comprehensive disease management/self-care
    programs.

    Interventions vary by characteristics of the disease (e.g.,
    life threatening) degree of functional and role
    impairment, amount of pain and discomfort, and
    available supports.

    Help in coping with emotions
    accompanying illness and
    treatment.

    Community and peer support programs.
    Coaching/supportive counseling for patient and family.
    Pharmacological treatment for depression/anxiety

    coupled with psychotherapy.
    Pain and coping skills training for pain and discomfort.

    Assistance in changing behaviors
    to minimize impact of disease and
    treatment and manage their
    effects.

    Health promotion interventions such as:
    Assessment/monitoring of key health behaviors such as

    diet, smoking, exercise.
    Medication counseling/brief physician counseling.

    Material and logistical resources
    such as transportation, home
    care.

    Community and financial resources.
    Access to home care and environmental alterations.
    Information to informal caregivers.

    Help in managing disruptions in
    work, activities, family life, and
    social network.
    Prepare for care transitions due
    to disease progression.

    Family/caregiver education, counseling.
    Assistance with activities of daily living (ADLs), and

    instrumental activities/chores (IADLS).
    Information on legal protections and services.
    Ongoing social network development.

    Financial advice and/or
    assistance. Managing and

    Assist with financial planning/counseling including
    management of activities such as bill paying.

    9

    Christ & Diwan Chronic Illness—Role of Social Work
    Biopsychosocial Health
    Needs
    Evidence Informed Services for Addressing
    Needs

    maintaining health insurance over
    time.

    Insurance counseling/advocacy.
    Eligibility assessment for supplemental income benefits

    and assistance with major out of pocket expenses.

    Adapted from a report by the Institute of Medicine titled Cancer Care for the Whole Patient: Meeting 
    Psychosocial Health Needs, 2007. Available at: http://www.nap.edu/catalog/11993.html.  

    Care Coordination as a Model of Health Services Delivery:
    The Evidence Base

    What Is Care Coordination?

    Care coordination is the deliberate organization of patient care activities 
    between two or more participants (including the patient) involved in a patient’s 
    care to facilitate the appropriate delivery of health care services (McDonald et 
    al., 2007).  

    This overarching construct includes programs of intervention that have been 
    referred to by such terms as disease management, case/care management, 
    multidisciplinary team management, and patient navigation. Social workers are 
    increasingly called on to participate in the development and implementation of these 
    programs because they often incorporate many social work functions and provide 
    major opportunities to improve the quality and effectiveness of patients’ health care, a 
    core social work commitment. 

    The Need for Care Coordination

    The structure of the health care delivery system in the U.S. is marked by 
    fragmentation, complexity, pervasive deficiencies, and remarkable variation in 
    patient safety and healthcare quality (McDonald et al, 2007).  

    Additionally, older patients are more vulnerable to the negative consequences 
    of this fragmentation as they often have complex management regimens for 
    their chronic conditions, strained or reduced family support, and lower health 
    literacy (McDonald et al, 2007). 

    The range of psychosocial services described earlier that are useful in 
    improving the health and quality of life of elders are located in various delivery 
    systems in the community, making it difficult for elders and families to access 
    these services. 

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    Christ & Diwan Chronic Illness—Role of Social Work

    The following summary statement characterizes the view of many health 
    professionals about current challenges to the health care system. 

    Providers and decision makers at the health service delivery level are caring for 
    patients with increasing needs for coordination services in a system that is 
    progressively becoming more fragmented. Physicians report that time constraints are a 
    major barrier to patient care. Coordinating care for patients takes time; time that is 
    typically not reimbursed. As the population ages, as the number of people with 
    multiple chronic medical problems increases, and as patients see more doctors and 
    receive care at a greater number of healthcare settings, the need to coordinate care will 
    continue to increase. This increase in need is occurring in an environment in which cost 
    containment efforts result in decreased access to social support services. While the need 
    for coordination increases, healthcare providers frequently lack the infrastructure and 
    resources to respond to their patient’s needs.  
    (McDonald et al., 2007, p. 32) 

    These new challenges to the health care system have led to widespread interest in 
    ways to improve the effectiveness and efficiency of medical care for chronic conditions. 
    In the last decade, one intervention has received increasing attention in work with older 
    adults with chronic illnesses: coordination of care.  

    In 2003, the IOM identified care coordination as among the key strategies to deal 
    with escalating problems in the treatment of chronic conditions (IOM, 2003). In 2007, 
    the Agency for Health Care Research and Quality (AHRQ) issued a review and 
    synthesis of the evidence base for the effectiveness of these approaches to intervention 
    (McDonald et al., 2007). It provided a working definition of care coordination programs, 
    identified the range of components, provided a critique of their effectiveness, and made 
    suggestions for future program development and research.  

    Models of Care Coordination Programs

    The need for care coordination is critical at several points in the health care 
    delivery system and several models of care coordination programs have been 
    developed to address specific needs.  

    Table 3 below outlines some of the major models of care coordination and, 
    for each model, provides an example of an evidence‐supported care 
    coordination program and its specific outcomes. Many of these models of 
    care coordination include social workers in the intervention. Readers are 
    referred to the 2008 Institute of Medicine (IOM) report, the National 
    Registry for Evidence‐based Programs (NREPP), the Centers for Disease 
    Control and Prevention (CDC), and Care Transitions.Org for more details 
    on each program.  

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    Christ & Diwan Chronic Illness—Role of Social Work

    Table 3. Models of Care Coordination and Selected Evidence

    1. INTERDISCIPLINARY TEAM CARE
    Providers from different disciplines collaboratively manage the care of a patient.
    Example: Program for All-Inclusive Care for the Elderly (PACE).
    Specific Aim: Within a managed-care program (for those eligible for Medicaid and Medicare),
    address the spectrum of needs for adults aged 55 and older whose disability level qualifies them for
    nursing-home care.
    Intervention: PACE services are provided by an interdisciplinary team composed of at least the
    following members: a primary care physician, a registered nurse, a social worker, a physical
    therapist, a pharmacist, an occupational therapist, a recreational therapist, a dietician, a PACE
    center-manager, a home-care coordinator, personal care attendants, and drivers. PACE has an
    innovative team approach as it includes both professionals and direct-care workers as part of the
    care team. Each member of the team performs an initial assessment of each patient, and then the
    group works together to create a single care plan that takes the different assessments into account.
    The services, which are provided primarily at an adult day-care center, are also highly coordinated.
    Outcomes: PACE enrollees showed higher patient satisfaction, improved health status and physical
    functioning, an increased number of days in the community, improved quality of life, and lower
    mortality. The benefits of PACE were even greater for the frailest older adults, who had lower rates
    of service utilization in hospitals and nursing homes and higher rates of ambulatory care services.
    Source: Institute of Medicine, 2008. Retooling for an Aging America: Building the Health Care
    Workforce. http://www.iom.edu/?ID=53452

    2. CARE MANAGEMENT
    In most forms, a nurse or social worker provides patients (and sometimes families) a combination of
    health assessment, planning, education, behavioral counseling, and coordination. Their
    communication with primary care providers varies depending on the care-management program.
    Example: Improving Mood: Promoting Access to Collaborative Treatment for Late Life Depression
    (IMPACT)
    Specific Aim: To treat depression in primary care settings because depression is common among
    individuals with chronic illness.
    Intervention: Patients participating in IMPACT receive educational materials about late-life
    depression and visit a depression-care manager at a primary care clinic. The care managers
    (typically nurses, psychologists, and social workers) are trained as depression clinical specialists
    and work with the patient’s regular primary care provider to establish a treatment plan. Care
    managers are supervised by a team psychiatrist and a primary care physician. Results indicate that
    evidence-based care for major depression can be successfully delivered by specially trained nurses,
    psychologists, and social workers in primary care settings.
    Outcomes: IMPACT participants had higher rates of depression treatment, greater reductions in
    depressive symptoms, more satisfaction with their care, less functional impairment, greater quality of
    life, and more depression-free days. Positive results were maintained over 1 year.
    Source: Institute of Medicine, 2008. Retooling for an Aging America: Building the Health Care
    Workforce. http://www.iom.edu/?ID=53452

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    Christ & Diwan Chronic Illness—Role of Social Work

    3. CHRONIC DISEASE SELF-MANAGEMENT PROGRAMS
    Self-management programs are structured, time-limited interventions designed to provide health
    information and to empower patients to assume an active role in managing their chronic conditions.
    Some are led by health professionals and focus on the management of specific conditions, such as
    stroke, while others are led by trained laypersons and address chronic conditions more generally.
    Example: Chronic Disease Self-Management Program (CDSMP)
    Specific Aim: To teach self-management skills useful for managing a variety of chronic diseases such
    as arthritis, diabetes, lung and heart disease.
    Intervention: CDSMP workshops are held in community settings and meet 2 1/2 hours per week for
    6 weeks. Workshops are facilitated by two trained leaders, one or both of whom are non-health
    professionals living with a chronic disease. This program covers topic such as techniques to deal
    with problems associated with chronic disease; appropriate exercise; appropriate use of
    medications’ communicating effectively with family, friends, and health professionals; nutrition; and
    how to evaluate new treatments.
    Outcomes: Participants in the CDSMP have shown significant improvements in exercise,
    communication with physicians, self-reported general health, health distress, fatigue, disability, and
    social/role activities limitations.
    Source: CDC. http://www.cdc.gov/arthritis/intervention/index.htm

    4. PREVENTIVE HOME VISITS
    Home visits are provided to older persons by nurses or other visitors to monitor health and
    functional status and to encourage self-care and appropriate use of health care services. These
    visitors usually see their clients quarterly and communicate regularly with their clients’ primary care
    providers.
    Example: Geriatric Resources for Assessment and Care of Elders (GRACE)
    Specific Aim: Providing health care for low-income older adults as they face several challenges,
    including high incidence of chronic illness, limited access to care, low health literacy, and
    socioeconomic stressors that lead to unmet need and greater burden of illness.
    Intervention: A team consisting of a nurse practitioner and a social worker visits patients at their
    homes for an initial assessment and then follows up with the patients at least once a month, either
    by phone or face-to-face. Home visits are also conducted after any emergency-department or
    hospital visit. This two-person team is supported by an interdisciplinary team led by a geriatrician
    that includes a pharmacist, physical therapist, mental health social worker, and community-based
    services liaison. This group, using input from the patient’s primary care physician, establishes a care
    plan for the patient that incorporates protocols for the treatment of 12 targeted geriatric conditions.
    Outcome: A controlled clinical trial of the GRACE program indicates improved quality of care and
    reduced acute-care utilization. However, improvements in health-related quality of life were mixed,
    and physical functional outcomes did not differ from the control group.
    Source: Institute of Medicine, 2008. Retooling for an Aging America: Building the Health Care
    Workforce. http://www.iom.edu/?ID=53452

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    Christ & Diwan Chronic Illness—Role of Social Work

    5. CAREGIVER EDUCATION AND SUPPORT
    These community-based programs are designed to help the informal caregivers of older persons
    with chronic conditions such as dementia and stroke. Led by psychologists, social workers, or
    rehabilitation therapists, these programs provide varying combinations of health information,
    training, access to professional and community resources, emotional support, counseling, and
    coping strategies.
    Example: Resources for Enhancing Alzheimer’s Caregiver Health II (REACH II)
    Specific Aim: Support caregivers of persons with dementia.
    Intervention: Provide educational information, skills to manage care recipient behaviors, social
    support, cognitive strategies for reframing negative emotional responses, and strategies for
    enhancing healthy behaviors and managing stress. Methods used in the intervention include
    didactic instruction, role-playing, problem-solving tasks, skills training, stress management
    techniques, and telephone support groups.
    Outcome: Caregivers in the REACH II intervention group experienced greater improvement in
    quality of life and fewer cases of clinical depression.
    Source: National Registry of Evidence-Based Programs and Practices, SAMHSA.
    http://www.nrepp.samhsa.gov/

    6. TRANSITIONAL CARE
    Typically a nurse or an advance-practice nurse prepares and coaches the patient and informal
    caregiver for the transition from hospital discharge to home care.
    Example: The Care Transitions Program
    Specific Aim: To help patients with complex care needs learn self-management skills to ensure their
    needs are met during the transition from hospital to home.
    Intervention: For 4 weeks after discharge the nurse visits the patient at home to ensure that all
    needed medication, equipment, and supplies are available, and that the patient and caregiver
    know how to use them, how to self-monitor, and whom to call if problems arise. The nurse continues
    to monitor the situation for several weeks until the patient has returned to pre-admission status,
    contacting the primary care physician as needed.
    Outcome: Intervention patients had fewer hospital readmissions, reported high levels of confidence
    in obtaining essential information for managing their condition, communicating with members of the
    health-care team, and understanding their medication regimen (Coleman et al., 2004).
    Source: The Care Transitions Program. www.CareTransitions.org

  • Features of Innovative Care Coordination Models
  • The IOM (2008) committee report did not attempt to rank the models described 
    above or to recommend one model of care over another. In fact, little evidence exists 
    that one might use to rate the relative effectiveness of these different approaches. 
    Typically, evaluations focus on whether a single model proved to be successful rather 
    than identifying which of several models produced the strongest results.  

    14

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    The Care Transitions Program

    Christ & Diwan Chronic Illness—Role of Social Work

    The committee concluded that no single one of the models described above 
    would be sufficient to meet the needs of all older adults. The health care needs 
    of the older population are diverse, and addressing those needs requires 
    varying models of care to meet their specific requirements.  

    For example, preventive home visits may be too costly to expand to all older 
    persons, the majority of whom may not even require that level of care. Similarly, 
    caregiver‐support programs may not be sufficient for older adults with more intensive 
    needs. The models described above have generally been successful in enrolling mainly 
    those older adults who would best benefit from the particular expanded services. 

    After reviewing the evidence on a number of different models of care, the IOM 
    committee concluded that some of the models with the strongest evidence of 
    success in improving care quality, health‐related outcomes, or efficiency have 
    common features that may contribute to their success. 

    Common components of care coordination programs include the following:  
    1) Essential care tasks (e.g., assess client and develop a care plan) 
    2) Associated coordination activities (e.g., service arranging, psycho‐

    education) 
    3) Common features of interventions to support coordination activities (e.g., 

    standardized protocols and manuals, multidisciplinary teams). 
    Key aspects of these care coordination interventions are thoroughly integrated in 

    the social work profession’s knowledge, skill, and value base: 
    1) Patient education 
    2) Self management  
    3) Provider education 
    4) Provider reminders to patients (e.g., regarding appointments, procedures) 
    5) Audit and feedback 
    6) Relay of clinical data  
    7) Organizational change (e.g., adding staff, changing or adding programs)  
    8) Financial and regulatory incentives (e.g., compensated time for patient 

    education). 

    Evidence for the Relative Efficacy of Various Care Coordination Programs

    The evidence base for the effectiveness of various care coordination is 
    substantial but not sufficient, and the comparative usefulness of various 
    programs is unknown. 

    15

    Christ & Diwan Chronic Illness—Role of Social Work

    Although there is substantial evidence for the effectiveness of care coordination 
    programs, it currently is not adequate to determine the relative effectiveness of any 
    particular strategy compared to other strategies in improving patient outcomes. Because 
    few intervention studies have clearly identified their component parts, the specific 
    aspects of these interventions that are most effective also are unknown.  

    The AHRQ’s examination of 75 systematic reviews provides an up‐to‐date 
    evaluation of the evidence base for care coordination interventions (McDonald et al., 
    2007). From these reviews, 20 different interventions were identified that had been 
    implemented in multiple settings and that covered 12 clinical populations spread across 
    the settings. Specific components of care coordination were clarified to support the 
    analysis.  Overall, this synthesis found that care coordination interventions improved 
    important patient outcomes in different diseases across a broad spectrum of clinical 
    settings.  

    The AHRQ report (McDonald et al., 2007) included the following overall benefits of 
    care coordination:  

    Care coordination strategies for older adults have resulted in reduced 
    numbers of hospital admissions.  

    Interventions by multidisciplinary teams have improved continuity of 
    service for severely mentally ill patients, reduced mortality and hospital 
    admissions for heart failure patients, reduced symptoms for terminally ill 
    patients, and reduced mortality and dependency for stroke patients.  

    Disease management programs have reduced severity of depression and 
    improved adherence to treatment in patients with mental illness, reduced 
    mortality and hospital admissions in patients with heart failure, and 
    improved glycemic control in patients with diabetes.  

    Case management programs have shown reduced rates of rehospitalization 
    among patients with mental health problems, and improved glycemic 
    control among patients with diabetes.  

    Despite the above findings, unclear definitions and descriptions of the specific 
    components used in most care coordination interventions make it difficult to determine 
    which specific components were affecting the outcomes. Therefore, continued well‐
    designed research in this area is needed. 

     

    16

    Christ & Diwan Chronic Illness—Role of Social Work

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    McInnis‐Dittrich, K. (2004). Social work with elders: A biopsychosocial approach to assessment 
    and intervention (2nd ed.). Boston: Allyn and Bacon. 

    National Association of Social Workers. (2005). NASW standards for social work practice in 
    health care settings. Retrieved June 15, 2008, from 
    http://www.socialworkers.org/practice/standards/NASWHealthCareStandards  

    Unger, J. B., McAvay, G., Bruce, M. L., Berkman, L., & Seeman, T. (1999). Variation in 
    the impact of social network characteristics on physical functioning in elderly 
    persons: MacArthur studies of successful aging. Journals of Gerontology: Social 
    Sciences, 54B(5), S245‐S251. 

    Urdangarin, C. F. (2000). Comprehensive geriatric assessment and management. In R. L. 
    Kane & R. A. Kane (Eds.), Assessing older persons: Measures, meanings, and practical 
    applications (pp. 383‐ 405). New York: Oxford University Press. 

    18

    http://www.nap.edu/openbook.php?isbn=0309085438

    http://www.nap.edu/catalog/11993.html

    http://www.iom.edu/?ID=53452

    http://www.socialworkers.org/practice/standards/NASWHealthCareStandards

    Christ & Diwan Chronic Illness—Role of Social Work

    Widlitz, M., & Marin, D. B. (2002). Substance abuse in older adults: An overview. 
    Geriatrics, 57(12), 29‐34. 

    Wieland, D, & Hirth, V. (2003). Comprehensive geriatric assessment. Cancer Control, 
    10(6), 454‐462.  

    19

    Christ & Diwan Chronic Illness—Role of Social Work

    Curriculum Resources

    Suggested Readings:

    Comprehensive Text Books on Social Work in Health and Aging

    Berkman, B. (Ed.). (2006). Handbook of social work in health and aging. New York:
    Oxford University Press.

    Gelhert, S., & T. A. Browne (Eds.). (2006). Handbook of health social work, New
    York: Wiley.

    Kane, R. L., & Kane, R. A. (2000). Assessing older persons: Measures, meaning, and
    practical applications. New York: Oxford University Press.

    McInnis-Dittrich, K. (2005). Social work with elders: A biopsychosocial approach to
    assessment and intervention. Boston: Allyn and Bacon.

    Class Assignment: Group Project for Health Care

    In the context of an ever-changing health care environment, the ability to define social work roles
    and to be able to advocate for social work programs in the field of health is critical. This
    assignment is an opportunity to design and present a proposal for a new service or program in a
    setting of your choosing (i.e., hospital, outpatient, prevention agency, specialty clinic, advocacy).
    Working in a group of students, you are expected to identify a specific need and population and
    prepare a 30-minute presentation on this topic. This presentation will have several key
    components:

    Statement of the problem and why services are needed:

    What is the scope of the problem areas

    What is known and how is it relevant to social work practice

    Findings from literature review:

    How has the problem been studied or evaluated

    What literature exists about practice approaches and methods

    Description of the program or service:

    Introduce your intervention strategy

    20

    Christ & Diwan Chronic Illness—Role of Social Work

    Presentation of practice issues and plan for implementing the intervention:

    How will you begin

    How will individuals find out about/gain access to your program/service

    How do you anticipate that other health professionals will respond and/or interact
    with this intervention

    Description of resources that would be needed to implement the intervention.

    Definition of ways to evaluate the success of your program/service:

    Review of literature to identify ways to evaluate this program/service

    Identify evaluation instruments that you would use

    Identify how this relates to other setting and community resources:

    Identify how this relates to other setting and community resources

    Identify relevant government/other agencies to this client population

    Discuss opportunities for partnerships or possible overlap with
    other programs that will need to be considered.

    You are encouraged to interview professionals in the field to get ideas and strategies. This
    presentation should be targeted to an inter-professional decision-making audience as if you were
    presenting this to a committee in the setting that you have chosen.

    The group is expected to provide the instructor with the following prior to the presentation:

    an outline of the presentation (this may be a print out of PowerPoint slides)

    a copy of all handouts

    a reference list of key literature used in your research of the presentation and any
    additional resources you found helpful.

    All group members are expected to share delivering the presentation to the class. Ten minutes will
    be allotted following the presentation for questions and discussion. Peer feedback/evaluation will
    be included although the final grade for this assignment will be given by the instructor.

    Note: This assignment was submitted for inclusion in this module by:

    Susan Blacker, BSW, MSW, RSW
    Adjunct Professor, University of Toronto School of Social Work
    Director, Oncology Integration
    St. Michael’s Hospital
    Toronto, Ontario

    21

    Christ & Diwan Chronic Illness—Role of Social Work

    Teaching Modules and Films and Media:

    Resources for Screening and Biopsychosocial Assessment

    John A. Hartford Institute for Geriatric Nursing Try This.
    Try This: Best Practices in Nursing Care to Older Adults is a series of assessment tools to provide
    knowledge of best practices in the care of older adults. Includes:

    A general assessment tool (SPICES)
    The Katz Index of Independence in Activities of Daily Living
    The Lawton Instrumental Activities of Daily Living Scale
    Fall Risk Assessment
    Mental Status Assessment of Adults (Mini-Cog)
    The Geriatric Depression Scale (GDS) in English or Spanish
    Alcohol Use Screening and Assessment
    Modified Caregiver Strain Index
    Elder Mistreatment Assessment in English or Spanish

    The Try This resources were developed for a nursing curriculum, but they are quite appropriate for
    social work students and practitioners.

    The videos include a demonstration of the instrument, a discussion of the problem, debriefing, and
    the implications of the assessment for intervention/ treatment planning after the assessment. The
    assessments are conducted in a hospital setting, so instructors may need to discuss with their
    students the influence of context on the process of evaluation.

    Overall, the quality of the videos is good as are the other Try This resources.

    (See below for links to demonstration videos of the various instruments.)
    http://www.hartfordign.org/trythis

    [To show these in full screen, you will need to click the full screen icon in the lower right corner.]

    Resources for Health Care Issues and Ethnic Diversity

    Stanford Geriatric Education Center
    http://sgec.stanford.edu/
    The SGEC has many valuable resources that can help faculty who need health-related
    information about older adults. In particular, this center offers excellent on-line training
    resources on racial and ethnic diversity that include:

    Curriculum in Ethnogeriatrics
    A comprehensive curriculum in the health care of elders from diverse ethnic

    22

    http://www.hartfordign.org/trythis

    http://sgec.stanford.edu/

    Christ & Diwan Chronic Illness—Role of Social Work

    populations for training in all health care disciplines. It includes five Core
    Curriculum modules and eleven Ethnic Specific Modules to be used in
    conjunction with the Core Curriculum.

    Diabetes and Mental Health
    Developed as a resource for teaching culturally appropriate care for
    depression and cognitive loss for elders at high risk for diabetes.

    Improving Communication with Elders of Different Cultures
    Provides information on how to recognize barriers to communication with
    elders who are culturally or ethnically different from the health care provider,
    and some culturally sensitive approaches to elicit information and promote
    shared decision-making and mutual respect.

    Diversity, Healing, and Healthcare
    Contains information about communication and healthcare beliefs related to
    15 cultures, 11 religions, and 8 American immigrant cohorts.

    Web Resources:

    General Chronic Care Information

    Healthy Aging: http://www.cdc.gov/aging
    Contains excellent overviews of issues related to chronic diseases, caregiving, and
    end-of-life, and provides examples of state programs.

    National Chronic Care Consortium: http://www.nccconline.org/
    This organization is dedicated to transforming the delivery of chronic care
    services. It provides access to advanced knowledge for serving people with
    multiple, complex chronic conditions. It offers tools and methods for addressing
    numerous aspects of integration of care for people with serious chronic conditions.

    National Registry of Evidence-Based Programs and Practices:
    http://www.nrepp.samhsa.gov/
    NREPP is a searchable database of interventions for the prevention and treatment
    of mental and substance use disorders. SAMHSA has developed this resource to
    help people, agencies, and organizations implement programs and practices in
    their communities. Also contains information on health care and caregiver support
    programs.

    Disease-Related Information

    Alzheimer’s Association: http://www.alzheimers.org/
    Comprised of a network of chapters, the Alzheimer’s Association is one of the

    23

    http://sgec.stanford.edu/training/cultures.html

    http://www.gasi-ves.org/diversity.htm

    http://www.cdc.gov/aging

    http://www.nccconline.org/

    http://www.nrepp.samhsa.gov/

    http://www.alzheimers.org/

    Christ & Diwan Chronic Illness—Role of Social Work

    largest voluntary organizations studying the disease and providing support to
    caregivers.

    American Cancer Society: http://www.cancer.org/

    Provides information for patients, families, health care providers. Also has
    materials in Spanish and some Asian languages.

    American Diabetes Association:
    http://www.diabetes.org/main/application/commercewf
    News, recipes, tip of the day and resources to help users find local help.

    American Heart Association National Center:
    http://www.americanheart.org/presenter.jhtml?identifier=1200000
    Includes risk assessment for heart attack and stroke, resources for advocates and
    scientists, and a “Heart and Stroke A-Z” guide.

    American Stroke Association:
    http://www.strokeassociation.org/presenter.jhtml?identifier=1200037
    Sponsored by the American Heart Association, this group provides resources for
    doctors, and patients and their caregivers.

    The Arthritis Foundation: http://www.arthritis.org/
    Connects users with events, treatments, research, advocacy, and goods related to
    arthritis. A zip code search provides information on the nearest Foundation
    chapter.

    Introduction to Diabetes: http://diabetes.niddk.nih.gov/intro/index.htm
    From the NIH-sponsored National Institute of Diabetes and Digestive and Kidney
    Diseases, this page contains tips on how to take care of diabetes and how to
    prevent some of the serious problems that the disease can cause.

    Foundation for Osteoporosis Research and Education: http://www.fore.org/
    A nonprofit resource center dedicated to preventing osteoporosis through research
    and education of the public and medical community. Includes links to an
    educational video available at the National Osteoporosis Foundation.

    National Stroke Association: http://www.stroke.org/
    A group dedicated to education, services, and community-based activities in
    prevention, treatment, rehabilitation, and recovery from stroke.

    Parkinson’s Disease Foundation: http://www .org/index.cfm
    Features news, “ask the expert,” and an email newsletter.

    24

    http://www.cancer.org/

    http://www.diabetes.org/main/application/commercewf

    http://www.americanheart.org/presenter.jhtml?identifier=1200000%20

    http://www.strokeassociation.org/presenter.jhtml?identifier=1200037%20

    http://www.arthritis.org/

    http://diabetes.niddk.nih.gov/intro/index.htm

    http://www.fore.org/

    http://www.stroke.org/

    http://www .org/index.cfm

      Grace Christ and Sadhna Diwan*
      Synopsis

    • Characteristics of Chronic Illness as They Impact the Social Work Role
    • Psychosocial Assessment of Older Adults with Chronic Conditions
      Comprehensive Assessments
      Process of Conducting Geriatric Assessments
      Biopsychosocial Framework for Seven Domains of Assessment
      Table 1. Biopsychosocial Assessment Domains and Specific Areas of Assessment Related to Chronic Illness Care
      Major Domains of Assessment
      Current Evidence or Rationale Supporting Specific Areas of Assessment Within Each Domain
      Table 1 continued…
      Biopsychosocial Needs and Services for Chronic Illness Care
      Table 2. Biopsychosocial Health Needs of Chronically Ill Older Adults and Evidence-Informed Services

    • Care Coordination as a Model of Health Services Delivery: The Evidence Base
    • What Is Care Coordination?
      The Need for Care Coordination
      Models of Care Coordination Programs
      Table 3. Models of Care Coordination and Selected Evidence
      Features of Innovative Care Coordination Models
      Evidence for the Relative Efficacy of Various Care Coordination Programs
      References

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