Better Transitions of Care to Bridge Gaps, Reduce Hospitalizations and Readmissions in IPF

White Paper

Better Transitions of Care to Bridge Gaps, Reduce Hospitalizations and Readmissions in IPF is a transitions of care white paper that incorporates essential interventions and tools designed to ensure effective and safe transitions of care for patients with idiopathic pulmonary fibrosis (IPF) across healthcare settings.

Safer Transitions, Fewer Re-Hospitalizations with PAH: An Interdisciplinary Guide

White Paper

PAH White Paper is a transitions of care white paper that was developed by NTOCC and Case Management Society of America (CMSA) for system leaders and interprofessional clinical team members who treat and manage patients with Pulmonary Arterial Hypertension (PAH).

Relationship Between Early Physician Follow-up and 30-Day Readmission Among Medicare Beneficiaries Hospitalized for Heart Failure

Journal Article

Hernandez AF, Greiner MA, Fonarow GC, et.al. Relationship Between Early Physician Follow-up and 30-Day Readmission Among Medicare Beneficiaries Hospitalized for Heart Failure. JAMA. 2010 303:1716-1722....

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Hernandez AF, Greiner MA, Fonarow GC, et.al. Relationship Between Early Physician Follow-up and 30-Day Readmission Among Medicare Beneficiaries Hospitalized for Heart Failure. JAMA. 2010 303:1716-1722. http://jama.jamanetwork.com/article.aspx?articleid=185798 Accessed August 7, 2014. Context Readmission after hospitalization for heart failure is common. Early outpatient follow-up after hospitalization has been proposed as a means of reducing readmission rates. However, there are limited data describing patterns of follow-up after heart failure hospitalization and its association with readmission rates.

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Medicaring.org

Web Site

Altarum Institute. Medicaring.org. [Web site]. http://medicaring.org/Updated 2013. Accessed July 30, 2014. Medicaring is the exciting idea that Americans can learn to build reliable, effective, and efficient arrangements for services to support one...

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Altarum Institute. Medicaring.org. [Web site]. http://medicaring.org/Updated 2013. Accessed July 30, 2014. Medicaring is the exciting idea that Americans can learn to build reliable, effective, and efficient arrangements for services to support one another when we must live with serious chronic conditions, mostly associated with older age or the last years of life — and that such a care system will be substantially different from what we have now. We are working on policy, economics, professional development, public education, community demonstrations and a dozen other fronts to learn what works and to forge the commitment to change.

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From Hospital to Home: Assessing the Transitional Care Needs of Vulnerable Seniors

Journal Article

Graham C, Ivey S, Neuhauser L. From Hospital to Home: Assessing the Transitional Care Needs of Vulnerable Seniors. The Gerontologist. 2009;49 (1): 23-33. http://gerontologist.oxfordjournals.org/content/49/1/23. Accessed July 30, 2014. Purpose: This...

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Graham C, Ivey S, Neuhauser L. From Hospital to Home: Assessing the Transitional Care Needs of Vulnerable Seniors. The Gerontologist. 2009;49 (1): 23-33. http://gerontologist.oxfordjournals.org/content/49/1/23. Accessed July 30, 2014. Purpose: This qualitative study assessed the needs of patients and caregivers during the transition from hospital to home. We specifically identified unmet needs of ethnic minorities, recent immigrants, and seniors with limited English proficiency (LEP). Findings are translated into recommendations for improving services to these groups during health care transitions. Design and Methods: This needs assessment included extensive analysis of qualitative data collected from 20 language-, culture-, and ethnic-specific focus groups with caregivers who recently assisted a senior after a hospital discharge. Findings from these focus groups were supplemented by 5 in-depth, longitudinal case studies of recently hospitalized seniors and their caregivers. Results: Inadequate information and training at discharge were themes that spanned all groups, despite ethnicity or language. Additional unmet needs were identified for ethnic minorities, those with LEP, and recent immigrants, including lower levels of social support than might be expected, lack of linguistically appropriate information and services, and cultural and financial barriers to using long-term care services. Implications: As ethnic diversity increases among older Americans, it will become increasingly important to design health care services to meet the needs of diverse groups. Recommendations include assessments of informal care, bilingual information and services, partnerships with community agencies providing culturally competent services, and expansion of home- and community-based services to near-poor seniors.

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Creating an Accurate Medication List in the Outpatient Setting Through a Patient-Centered Approach.

White Paper

Leonhardt K , Pagel P, Bonin D, et al. Creating an Accurate Medication List in the Outpatient Setting Through a Patient-Centered Approach. Http://www.ahrq.gov/downloads/pub/advances2/vol3/advances-leonhardt_35.pdf. 2007. Accessed 7/9/14. Aurora...

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Leonhardt K , Pagel P, Bonin D, et al. Creating an Accurate Medication List in the Outpatient Setting Through a Patient-Centered Approach. Http://www.ahrq.gov/downloads/pub/advances2/vol3/advances-leonhardt_35.pdf. 2007. Accessed 7/9/14. Aurora Health Care partnered with Consumers Advancing Patient Safety (CAPS) and Midwest Airlines to implement a patient partnership model as an intervention to improve medication safety in the outpatient setting. Bringing patients and health care providers together with a common goal offered the opportunity for collaboration and insight to the needs of our patients.

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Defining and disseminating the hospital-at-home model

Journal Article

Leff B. Defining and disseminating the hospital-at-home model. CMAJ.2009;180(2):156-157.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2621275/. Accessed 7/9/14.The hospital, which is the "gold standard" for the delivery of acute medical care, is not an...

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Leff B. Defining and disseminating the hospital-at-home model. CMAJ.2009;180(2):156-157.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2621275/. Accessed 7/9/14.The hospital, which is the "gold standard" for the delivery of acute medical care, is not an ideal care environment for many patients.1 Iatrogenic events such as nosocomial infections, pressure sores, falls and delirium are common.2 New functional impairment commonly occurs during hospital stay. Suboptimal transitions in care at the time of hospital discharge also occur, contributing, ironically, to readmission to hospital.3 Furthermore, hospital care is very expensive. In this issue, Shepperd and colleagues4 present a meta-analysis of the effectiveness of "hospital-at-home programs."

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Improved Transitions of Patient Care Yield Tangible Savings

White Paper

Improving care transitions is not only an important component of ensuring the delivery of high quality care, it is also a way to reduce the cost of health care for patients, payers, and the system as a whole. Download this resource to learn more about the economic value of improved transitions of care, as well as emerging models.

Guided Care: Care for the Whole Person, For Those Who Need It Most

Web Site

Guided Care is a new solution to the growing challenge of caring for older adults with chronic conditions and complex health needs. A Guided Care Nurse, based in a primary care office, works with patients and their families to improve their quality...

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Guided Care is a new solution to the growing challenge of caring for older adults with chronic conditions and complex health needs. A Guided Care Nurse, based in a primary care office, works with patients and their families to improve their quality of life and make more efficient use of health services. The nurse assesses patient needs, monitors conditions, educates and empowers the patient, and works with community agencies to ensure that the patient’s healthcare goals are met. The Lipitz Center recently conducted a cluster-randomized controlled trial of Guided Care at eight community-based primary care practices in the Baltimore-Washington D.C. area that included over 900 patients, 300 caregivers, and 48 primary care physicians. Preliminary data indicate that Guided Care improves the quality of patients' care, reduces family caregiver strain, improves physicians' satisfaction with chronic care, and may reduce the use and cost of expensive services, especially in well-managed systems. Click here for a summary of preliminary data from the trial.

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The effects of guided care on the perceived quality of health care for multi-morbid older persons: 18-month outcomes from a cluster-randomized controlled trial

Journal Article

J Gen Intern Med, 25;3:235-42 Authors: Boyd, C. M., Reider, L., Frey, K., Scharfstein, D., Leff, B. Wolff, J., Groves, C., Karm, L., Wegener, S., Marsteller, J., Boult, C. BACKGROUND: The quality of health care for older Americans with chronic...

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J Gen Intern Med, 25;3:235-42 Authors: Boyd, C. M., Reider, L., Frey, K., Scharfstein, D., Leff, B. Wolff, J., Groves, C., Karm, L., Wegener, S., Marsteller, J., Boult, C. BACKGROUND: The quality of health care for older Americans with chronic conditions is suboptimal. OBJECTIVE: To evaluate the effects of ""Guided Care"" on patient-reported quality of chronic illness care. DESIGN: Cluster-randomized controlled trial of Guided Care in 14 primary care teams. PARTICIPANTS: Older patients of these teams were eligible to participate if, based on analysis of their recent insurance claims, they were at risk for incurring high health-care costs during the coming year. Small teams of physicians and their at-risk older patients were randomized to receive either Guided Care (GC) or usual care (UC). INTERVENTION: ""Guided Care"" is designed to enhance the quality of health care by integrating a registered nurse, trained in chronic care, into a primary care practice to work with 2-5 physicians in providing comprehensive chronic care to 50-60 multi-morbid older patients. MEASUREMENTS: Eighteen months after baseline, interviewers blinded to group assignment administered the Patient Assessment of Chronic Illness Care (PACIC) survey by telephone. Logistic and linear regression was used to evaluate the effect of the intervention on patient-reported quality of chronic illness care. RESULTS: Of the 13,534 older patients screened, 2,391 (17.7%) were eligible to participate in the study, of which 904 (37.8%) gave informed consent and were cluster-randomized. After 18 months, 95.3% and 92.2% of the GC and UC recipients who remained alive and eligible completed interviews. Compared to UC recipients, GC recipients had twice greater odds of rating their chronic care highly (aOR = 2.13, 95% CI = 1.30-3.50, p = 0.003). CONCLUSION: Guided Care improves self-reported quality of chronic health care for multi-morbid older persons.

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Guided care: cost and utilization outcomes in a pilot study

Journal Article

Dis Manag, 11;1:28-36 Authors: Sylvia, M. L., Griswold, M., Dunbar, L., Boyd, C. M., Park, M., Boult, C., Guided Care (GC) is an enhancement to primary care that incorporates the operative principles of disease management and chronic care...

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Dis Manag, 11;1:28-36 Authors: Sylvia, M. L., Griswold, M., Dunbar, L., Boyd, C. M., Park, M., Boult, C., Guided Care (GC) is an enhancement to primary care that incorporates the operative principles of disease management and chronic care innovations. In a 6-month quasi-experimental study, we compared the cost and utilization patterns of patients assigned to GC and Usual Care (UC). The setting was a community-based general internal medicine practice. The participants were patients of 4 general internists. They were older, chronically ill, community-dwelling patients, members of a capitated health plan, and identified as high risk. Using the Adjusted Clinical Groups Predictive Model (ACG-PM), we identified those at highest risk of future health care utilization. We selected the 75 highest-risk older patients of 2 internists at a primary care practice to receive GC and the 75 highest-risk older patients of 2 other internists in the same practice to receive UC. Insurance data were used to describe the groups' demographics, chronic conditions, insurance expenditures, and utilization. Among our results, at baseline, the GC (all targeted patients) and UC groups were similar in demographics and prevalence of chronic conditions, but the GC group had a higher mean ACG-PM risk score (0.34 vs. 0.20, p < 0.0001). During the following 6 months, the GC group had lower unadjusted mean insurance expenditures, hospital admissions, hospital days, and emergency department visits (p > 0.05). There were larger differences in insurance expenditures between the GC and UC groups at lower risk levels (at ACG-PM = 0.10, mean difference = $4340; at ACG-PM = 0.6, mean difference = $1304). Thirty-one of the 75 patients assigned to receive GC actually enrolled in the intervention. These results suggest that GC may reduce insurance expenditures for high-risk older adults. If these results are confirmed in larger, randomized studies, GC may help to increase the efficiency of health care for the aging American population.

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Early effects of "Guided Care" on the quality of health care for multimorbid older persons: a cluster-randomized controlled trial

Journal Article

J Gerontol A Biol Sci Med Sci, 63;3:321-7 Authors: Boult, C., Reider, L., Frey, K., Leff, B., Boyd, C. M., Wolff, J. L., Wegener, S., Marsteller, J., Karm, L., Scharfstein, D., BACKGROUND: The quality of health care for older Americans with...

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J Gerontol A Biol Sci Med Sci, 63;3:321-7 Authors: Boult, C., Reider, L., Frey, K., Leff, B., Boyd, C. M., Wolff, J. L., Wegener, S., Marsteller, J., Karm, L., Scharfstein, D., BACKGROUND: The quality of health care for older Americans with multiple chronic conditions is suboptimal. We designed ""Guided Care"" (GC) to enhance quality of care by integrating a registered nurse, intensively trained in chronic care, into primary care practices to work with physicians in providing comprehensive chronic care to 50-60 multimorbid older patients. METHODS: We hypothesized that GC would improve the quality of health care for this population. In 2006, we began a cluster-randomized controlled trial of GC at eight practices (n = 49 physicians). Older patients of these practices were eligible to participate if they were at risk for using health services heavily during the coming year. Teams of two to five physicians and their at-risk older patients were randomized to either GC or usual care (UC). Six months after baseline, participants rated the quality of their health care by answering validated closed-ended questions from telephone interviewers who were masked to group assignment. RESULTS: Of the 13,534 older patients screened, 2391 (17.7%) were eligible to participate in the study, of which 904 (37.8%) gave informed consent and were cluster-randomized. After 6 months, 93.8% and 93.2% of the GC and UC participants who remained alive and eligible completed telephone interviews. GC participants were more likely than UC participants to rate their care highly (adjusted odds ratio = 2.0, 95% confidence interval, 1.2-3.4, p =.006), and primary care physicians were more likely to be satisfied with their interactions with chronically ill older patients and their families (p <.05). CONCLUSIONS: GC improves important aspects of the quality of health care for multimorbid older persons. Additional data will become available as this trial continues.

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Successful models of comprehensive care for older adults with chronic conditions: evidence for the Institute of Medicine's "retooling for an aging America" report

Journal Article

J Am Geriatr Soc, 57;12:2328-37 Authors: Boult, C., Green, A. F., Boult, L. B., Pacala, J. T., Snyder, C., Leff, B., The quality of chronic care in America is low, and the cost is high. To help inform efforts to overhaul the ailing U.S....

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J Am Geriatr Soc, 57;12:2328-37 Authors: Boult, C., Green, A. F., Boult, L. B., Pacala, J. T., Snyder, C., Leff, B., The quality of chronic care in America is low, and the cost is high. To help inform efforts to overhaul the ailing U.S. healthcare system, including those related to the ""medical home,"" models of comprehensive health care that have shown the potential to improve the quality, efficiency, or health-related outcomes of care for chronically ill older persons were identified. Using multiple indexing terms, the MEDLINE database was searched for articles published in English between January 1, 1987, and May 30, 2008, that reported statistically significant positive outcomes from high-quality research on models of comprehensive health care for older persons with chronic conditions. Each selected study addressed a model of comprehensive health care; was a meta-analysis, systematic review, or trial with an equivalent concurrent control group; included an adequate number of representative, chronically ill participants aged 65 and older; used valid measures; used reliable methods of data collection; analyzed data rigorously; and reported significantly positive effects on the quality, efficiency, or health-related outcomes of care. Of 2,714 identified articles, 123 (4.5%) met these criteria. Fifteen models have improved at least one outcome: interdisciplinary primary care (1), models that supplement primary care (8), transitional care (1), models of acute care in patients' homes (2), nurse-physician teams for residents of nursing homes (1), and models of comprehensive care in hospitals (2). Policy makers and healthcare leaders should consider including these 15 models of health care in plans to reform the U.S. healthcare system. The Centers for Medicare and Medicaid Services would need new statutory flexibility to pay for care by the nurses, social workers, pharmacists, and physicians who staff these promising models.

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The geriatric floating interdisciplinary transition team

Journal Article

J Am Geriatr Soc, 58;2:364–70 Authors: Arbaje, A. I., Maron, D. D., Yu, Q., Wendel, V. I., Tanner, E., Boult, C., Eubank, K. J., Durso, S. C. Older adults often receive suboptimal care during hospitalizations and transitions to postacute...

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J Am Geriatr Soc, 58;2:364–70 Authors: Arbaje, A. I., Maron, D. D., Yu, Q., Wendel, V. I., Tanner, E., Boult, C., Eubank, K. J., Durso, S. C. Older adults often receive suboptimal care during hospitalizations and transitions to postacute settings. Inpatient geriatric services have been shown to increase care quality but have not improved patient outcomes consistently. Acute Care for the Elderly units improve patient outcomes but are resource intensive. Transitional care has been shown to reduce hospital readmissions and healthcare costs. This article describes the Geriatric Floating Interdisciplinary Transition Team (Geri-FITT), a model that combines the strengths of inpatient geriatric evaluation and comanagement and transitional care models by creating an inpatient comanagement service that also delivers transitional care. The Geri-FITT model is designed to improve the hospital care of older adults and their transitions to postacute settings. In Geri-FITT, a geriatrician-geriatric nurse practitioner team assesses patients, comanages geriatric syndromes, provides staff education, encourages patient self-management, communicates with primary care providers, and follows up with patients soon after discharge. This pilot cohort study of Geri-FITT included hospitalized patients aged 70 and older on four general medicine services (two Geri-FITT, two usual care) at an academic medical center (N=717). The study assessed the effect of Geri-FITT on patients' care transition quality (Care Transitions Measure) and their satisfaction with hospital care (four questions). The results indicate that Geri-FITT is associated with slightly higher, though not statistically significantly so, quality care transitions and greater patient satisfaction with inpatient care. Geri-FITT may be a feasible approach to enhancing inpatient management and transitional care for older adults. Further study of its effect on these and other outcomes in other healthcare settings seems warranted.

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Comprehensive primary care for older patients with multiple chronic conditions: "Nobody rushes you through"

Journal Article

JAMA, 304;17:1936–43 Authors: Boult, C., Wieland, G. D. Older patients with multiple chronic health conditions and complex health care needs often receive care that is fragmented, incomplete, inefficient, and ineffective. This article describes...

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JAMA, 304;17:1936–43 Authors: Boult, C., Wieland, G. D. Older patients with multiple chronic health conditions and complex health care needs often receive care that is fragmented, incomplete, inefficient, and ineffective. This article describes the case of an older woman whose case cannot be managed effectively through the customary approach of simply diagnosing and treating her individual diseases. Based on expert consensus about the available evidence, this article identifies 4 proactive, continuous processes that can substantially improve the primary care of community-dwelling older patients who have multiple chronic conditions: comprehensive assessment, evidence-based care planning and monitoring, promotion of patients' and (family caregivers') active engagement in care, and coordination of professionals in care of the patient--all tailored to the patient's goals and preferences. Three models of chronic care that include these processes and that appear to improve some aspects of the effectiveness and the efficiency of complex primary care--the Geriatric Resources for Assessment and Care of Elders (GRACE) model, Guided Care, and the Program of All-inclusive Care for the Elderly (PACE)--are described briefly, and steps toward their implementation are discussed.

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Joint Commission Center for Transforming Healthcare Releases Tool to Tackle Miscommunication Among Caregivers

Initiative

The Joint Commission Center for Transforming Healthcare released a new Hand-off Communications Targeted Solutions Tool™ (TST) to assist health care organizations with the process of passing necessary and critical information about a patient from one caregiver to the next, or from one team of caregivers to another, to prevent miscommunication-related errors.

Care Transition Bundle: Seven Essential Intervention Categories

White Paper

This is a bundle of essential care-transition intervention strategies that any provider interested in implementing improvements in care transition can consider for use. This bundle is applicable to any type of care transition “exchange” and is...

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This is a bundle of essential care-transition intervention strategies that any provider interested in implementing improvements in care transition can consider for use. This bundle is applicable to any type of care transition “exchange” and is categorized into main topics that are essential to any care transition with descriptive language and examples to aid the provider in adopting these strategies.

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One Patient, Many Places: Managing Health Care Transitions. A Report from the HMO Workgroup on Care Management

White Paper

HMO Workgroup on Care Management. One Patient, Many Places: Managing Health Care Transitions. AAHP-HIAA Foundation, Washington DC. http://www.caretransitions.org/documents/One%20Patient%20RWJ%20Report.pdf . Published February 2004. This report...

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HMO Workgroup on Care Management. One Patient, Many Places: Managing Health Care Transitions. AAHP-HIAA Foundation, Washington DC. http://www.caretransitions.org/documents/One%20Patient%20RWJ%20Report.pdf . Published February 2004. This report addresses how Managed Care Organizations can improve the quality of transitions of care for adult patients with complex acute or chronic conditions. Includes best practices, recommendations for action, and tools.

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NTOCC: Cultural Competence—Essential Ingredient for Successful Transitions of Care

White Paper

Health care professionals increasingly recognize the crucial role that culture plays in the health care of a client or patient and the need to deliver services in a culturally competent manner. Cultural competence is essential to successful,...

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Health care professionals increasingly recognize the crucial role that culture plays in the health care of a client or patient and the need to deliver services in a culturally competent manner. Cultural competence is essential to successful, client-/patient-centered transitions of care. This tool provides information about culture and cultural competence, as well as strategies and resources to enhance professionals’ capacity to deliver culturally competent services during transitions of care.

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Care management of patients with complex health care needs: Research Synthesis Report No. 19

White Paper

Brown R, Peikes D, Peterson G. Care management of patients with complex health care needs: Research Synthesis Report No. 19. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2009/rwjf49853/subassets/rwjf49853_1. December 2009. Accessed April...

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Brown R, Peikes D, Peterson G. Care management of patients with complex health care needs: Research Synthesis Report No. 19. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2009/rwjf49853/subassets/rwjf49853_1. December 2009. Accessed April 17, 2013. This synthesis looks at the evidence and explores the potential for care management to improve quality of care and reduce costs for people with complex health care needs. This synthesis addresses the following questions: 1. What is care management? 2. How are patients identified for care management programs? 3. Do research-based care management programs enhance quality and reduce costs for patients with complex health care needs? 4. What are the characteristics of successful care management programs? 5. How have research-based care management programs been adapted to real-world treatment settings? 6. How do payment policies influence the creation and success of care management programs?

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