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| Editors and Contributors | p. ix |
| Acknowledgments | p. xv |
| Introduction | p. xvii |
| Theoretical Concepts | |
| Chronic illness | p. 3 |
| Overview | p. 25 |
| Promising practices in acute/primary care | p. 39 |
| Promising practices in integrated care | p. 65 |
| Intervention components | p. 87 |
| Evaluation methods | p. 127 |
| Heal... MORE | p. 141 |
| Financing and payment | p. 167 |
| Education of the interdisciplinary team | p. 191 |
| Promising Practices | |
| Primary Care Models | |
| Coordination of care by guided care interdisciplinary teams | p. 209 |
| Care management plus | p. 221 |
| Medicare coordinated care | p. 229 |
| Transitional Care Models | |
| The care transitions intervention | p. 263 |
| Enhanced Discharge Planning Program at Rush University Medical Center | p. 277 |
| Integrated Models | |
| Summa Health System and Area Agency on Aging Geriatric Evaluation Project | p. 293 |
| Program of All-Inclusive Care for the Elderly (PACE) | p. 303 |
| Medicaid Models | |
| Introduction to Medicaid care management | p. 317 |
| The Aetna Integrated Care Management Model: a managed Medicaid paradigm | p. 325 |
| King County Care Partners: a community based chronic care management system for Medicaid clients with co-occurring medical, mental, and substance abuse disorders | p. 339 |
| Predictive Risk Intelligence SysteM (PRISM): a decision-support tool for coordinating care for complex Medicaid clients | p. 349 |
| High-risk patients in a complex health system: coordinating and managing care | p. 361 |
| The SoonerCare Health Management Program | p. 371 |
| Practice Change | |
| Introduction: practice change fellows initiatives | p. 379 |
| Interdisciplinary care of chronically ill adults: communities of care for people living with congestive heart failure in the rural setting | p. 383 |
| Collaborative care treatment of late-life depression: development of a depression support service | p. 391 |
| Geriatric Telemedicine: supporting interdisciplinary care | p. 407 |
| Integrated Patient-Centered Care: the I-PiCC pilot | p. 417 |
| Medicare Managed Care | |
| Longitudinal care management: High risk care management | p. 431 |
| International Care Coordination | |
| The experiences in the Republic of Korea | p. 441 |
| Index | p. 451 |
| Table of Contents provided by Ingram. All Rights Reserved. |