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Centers for Medicare and Medicaid Services (CMS)

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  • Patients with Parkinson’s Disease Often Lost to Follow-Up Care

    Telehealth visits can improve continuity of care, quality of life, and overall health for patients with Parkinson’s disease, recent research shows. Although Parkinson’s affects 1.2 million people in the United States, there is little research on people in later stages of the disease.

  • Detailed Resource Tools for Care Coordinators and Case Managers

    Case managers and care coordinators need such a wide range of knowledge about community resources to address their patients’ social determinants of health that resource tools can be a huge time-saver. For a care coordination program involving complex pediatric patients, leaders developed a series of nearly two dozen resource guides they call playbooks.

  • Inside the Indiana Complex Care Coordination Collaborative

    Indiana’s Medicaid program administrators found value in embedding nurse care coordinators in primary care practices to address social determinants of health and transitional care issues in a population of children with complex medical issues.

  • Indiana Medicaid Officials Embrace Care Coordination Project

    A project to improve care coordination for children with complex medical needs revealed well-trained nurse care coordinators could manage a 100-patient caseload and improve outcomes. Nurse care coordinators were embedded in primary care provider offices and were trained to provide care coordination, including helping patients with medical and social needs.

  • Better Care Communication Needed for Home Health

    Researchers wanted to know if there is an association between home health and gaps in care coordination among providers. They found patients receiving home healthcare are sicker, experienced more functional dependencies, and reported more preventable drug-drug interactions. While home health was not associated with a difference in gaps of care coordination, it was associated with twice the risk of a preventable adverse outcome.

  • Many Safety Net, Rural Hospitals Do Not Properly Address Social Needs

    Safety net hospitals, critical care hospitals, and rural hospitals often do less than needed to address the social determinants of health of their vulnerable populations, particularly during the COVID-19 pandemic, new research shows.

  • Primary Care Is on Life Support, But Case Management Could Be Antidote

    Primary care is facing decline due to financial factors and clinician burnout. One solution is to assign case managers or care coordinators to primary care offices to improve communication between primary care providers, hospitals, and other healthcare entities.

  • Better Care Coordination Needed for Interhospital Transfers

    Interhospital transfers can be challenging and frustrating for nursing staff — and sometimes dangerous and tragic for patients and their families. Health systems should pay more attention to how these transfers are handled and work to improve communication between sending and receiving hospitals.

  • Possible Solutions to Poor Interhospital Transfers

    Interhospital transfers can be frustrating to nurses and lead to worse outcomes for patients, research shows. But hospitals can take steps to improve the process and reduce risks for patients. The first step is to eliminate unnecessary transfers.

  • Intensive Care Management Works with Complex Medicaid Population

    One way to reduce costs among a population of high-cost, high-utilization Medicaid patients is to use intensive care management. In a study of an intervention involving a nonprofit organization that provides integrated care to complex patients, investigators found a reduction of more than $1,900 in total medical expense per member per month.