Findings from the Evaluation of 15 Medicare Coordinated Care Demonstration Programs Over 10 Years
Representatives of the successful programs concurred that reliance on highly educated and experienced registered nurses to provide the appropriate interventions to the right people appears to be one key — but not the only key — to reducing hospitalizations.
Some less successful programs used similar staff as care coordinators. The successful programs, however, were much more likely than the unsuccessful programs to provide
(1) frequent face-to-face contact with patients to build rapport;
(2) opportunities for face-to-face contact with a patient’s physician;
(3) strong patient education rooted in behavioral
(4) comprehensive management of care setting transitions;
(5) care coordinators serving as a communications hub among providers and between patient and providers;
(6) comprehensive medication management.
Burwell, S. M. (2014). Fifth report to Congress on the evaluation of the Medicare Coordinated Care Demonstration: Findings over 10 years. Retrieved from http://innovation.cms.gov/Files/reports/MedicareCoordinatedCareDemoRTC.pdf