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Defining the Problem: Care Coordination

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What is a chronic condition? A chronic condition is a health concern that will last more than a year, probably limit your activity, and need ongoing medical treatment. Diabetes and Heart Failure are examples of chronic conditions.

  • Nine out of ten Americans over the age of 65 have a chronic condition.
  • Six out of ten Americans over the age of 65 have two or more chronic conditions.
  • By the year 2020 there will be 157 million Americans with one chronic condition, and 81 million people with multiple chronic conditions. That's a lot of people coping with chronic illnesses.

People with more than one chronic condition often see many different doctors... Keeping track of what you are supposed to do for each condition and making sure you are on top of all your conditions can be a real challenge and very frustrating. Some people with many chronic conditions feel they spend their whole life managing their conditions.

"Care coordination" helps people get services, learn how their medicines work, understand treatments, track visits and referrals and much more. Care Coordination is also known as care management, case management, or disease management.

Care Coordination can focus on many different things. A few examples are:

  • Coordinating the medical services you receive
  • Helping you function more independently
  • Arranging for home based services and community resources
  • Helping with finding a nursing home or other facility that meets your needs
  • Helping you understand and manage specific diseases

The good news is there are care coordinators available to help people cope with their chronic conditions. Most care coordinators are registered nurses, who are trained to help people and their doctors keep all their care and services coordinated. Care Coordinators are provided by some Medicare Advantage Plans, by some community agencies, by some large provider groups and are available privately for pay. For more information on care coordinators visit the home page of the National Association of Professional Geriatric Care Managers.

Keeping care coordinated is especially important if you go from one place of care to another. There are times when you may end up going from home to the hospital to a nursing home and back to home. That is a lot of transitioning and it is easy to see how hard it would be to keep track of all your medications and treatments. Having a care coordinator can help you make sure everyone knows what is going on with your care and have the right information about your medications, allergies, treatments and other services.

Even without a care coordinator, you can do things to make sure you stay safe if you move from one place of care to another. A couple of examples include:

  • Keep an up to date list of all the medicines you take. Make sure that over the counter medicines, like aspirin and herbal supplements, and vitamins are on this list. If you go to the emergency room or hospital, take the list with you.
  • Consider wearing identification bracelets that would alert people that you have certain conditions or allergies in case you are unable to tell them. It is very common to see people with diabetes wear this type of bracelet.
  • Keep emergency contact information in your wallet in case of an emergency.
  • If you have an advance directive or living will, make sure your doctor has a copy and your family members have a copy.
  • Keeping an up to date list of your doctor's, pharmacy, and other people who provide health services to you.

External Source

Coleman EA, Min S, Chomiak A, Kramer AM. Post-hospital care transitions: Patterns, complications, and risk identification. Health Services Research, 2004 Mollica RL, Gillespie J; Partnership for Solutions, Johns Hopkins University. Care Coordination for People with Chronic Conditions, 2003. Accessed September 22, 2008. Available at

Schoen C et al. Taking the pulse of health care systems: Experiences of patients with health problems in six countries. Commonwealth Fund Survey, 2005. Abstract accessed September 22, 2008. Available at

National Institute of Diabetes and Digestive and Kidney Diseases. Accessed April, 2008. Available at

Author: Nancy Williams/Kathy Alsgaard

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