extended her message to all chronic health conditions. Regrettably, her family’s experience was typical of many of those with chronic illness—one of disjointed care, spotty communication between primary care providers and specialists, and frustration over not knowing where to turn in the community for help. Her son’s case involved untimely diagnosis, failure to provide information on the evidence-based guidelines for depression treatment, lack of a centralized care plan shared among providers and the school system, and a myriad of health insurance obstacles. William Bruning, representing the Mid-America Coalition on Health Care Community Initiative on Depression, responded to the recurring themes in Whitecotton’s presentation and provided an overview of how the coalition is addressing many of these breakdowns in the system (see Box 4-1).


Participants identified four key strategies to address the major barriers to achieving high-quality, well-coordinated care: (1) align financial incentives; (2) provide educational supports; (3) use patient-centered health records supported by information and communications technology; and (4) ensure accountability and define roles for care.

Align Financial Incentives

Aligning financial incentives to reward high-quality care was a resounding theme throughout the summit, but was viewed as particularly compelling by participants in the care coordination session. Currently, the health care financing system is oriented to reward care for acute episodes, administered by a single provider, as opposed to a continuum of care across multiple providers. The disconnect between a system designed for acute care and the needs of more than 125 million people in the United States with chronic conditions is profound (Partnership for Prevention, 2002). The session participants identified important opportunities to address this problem, underscoring the need for a shared vision around:

  • An operational construct—consistent with evidence-based medicine—of what good care coordination would be.

  • How care coordination would be measured.

  • How models of successful reimbursement for care coordination would be disseminated.

To initiate the identification of an operational construct of good care coordination, three elements of such a construct were identified: (1) technical quality or the comprehensiveness of care, (2) measures of efficiency, and (3) a patient-reported set of outcomes. Clearly, interdisciplinary teams of individuals with expertise in chronic diseases, in maximizing functional ability, in supporting family caregivers, in health education, and in social services are needed to specify these elements for chronic disease. Once these elements have been specified, internalized, and accepted by those who provide care, a reliable core set of measures and benchmarks can be established and serve as the basis for reimbursement, with financial incentives for more-effective implementation. This proposal parallels that of the finance group with regard to paying for performance and designing benefit packages around the creative accomplishment of better patient care.

Like the finance group, the care coordination group embraced the concept of budget neutrality. It was collectively acknowledged that effective care coordination could facilitate achieving the mandates of the Quality Chasm report to provide care “based on continuous healing relationships,” support “decision making [that] is evidence-based,” and “anticipate patients’ needs, rather than simply reacting to events” (IOM, 2001:8). Care could also be provided in a more cost-effective manner. For example, a heart failure patient who was gaining weight and becoming increasingly symptomatic could be recognized by means of a patient-initiated phone call and

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