The increased prevalence of chronic conditions has accelerated the need to better address the complex health and supportive service issues of affected individuals. This need is particularly relevant to older adults, whose numbers are growing rapidly. Eighty percent of Americans over 65 have at least one chronic disease; almost half have multiple chronic conditions.^1-3 Coordinated care programs that integrate medical and social services are increasingly emphasized and have been incorporated into new health reform models, including patient-centered medical homes and accountable care organizations. Yet, there remain significant gaps in the research related to care coordination. Further evidence—including evidence that addresses variability in program design, organizational setting, and available resources—can serve the dual purpose of identifying promising practices and advocating for increased access among aging populations.

The literature on care coordination for older adults currently includes strong evidence of effectiveness for a limited number of specific service models, including ones that provide comprehensive services utilizing an interdisciplinary clinic-based team^4-10 or address particularly high-risk transition periods.^{11, 12} However, there are insufficient data related to the many care coordination programs and practices that are implemented through organizations that lack staffing and resources for research and evaluation. In addition, more information is needed to better understand the holistic nature of services provided and their multiple impacts, as well as outcomes of services that are individualized to meet a patient's particular needs.¹³ Recommendations to address existing limitations include the following:

Focus on programs implemented outside of medical settings:

Comprehensive and reliable information on community-based programs—despite their proliferation—is lacking. Community-based programs are underrepresented in the literature, as they are less likely than clinic-based programs to include an evaluation component. If they include evaluation, they are less likely to have a strong research design, due to resource limitations and an emphasis on service delivery. Understanding processes and outcomes from more diverse organizational bases, including community-based organizations, senior centers, and Area Agencies on Aging, is required to inform best practices for care coordination, as these are the programs most likely to have a strong supportive services component. Opportunities for evaluation and dissemination of promising practices in these locations may be increased through academic-community partnerships and targeted funding opportunities. Also needed is more flexibility in the peer-reviewed literature, so as to reflect the challenges of implementing rigorous research protocols in community-based settings.

Increased use of mixed research methods:

Effectively drawing upon the strengths of both quantitative and qualitative methods facilitates a more accurate and thorough understanding of the impact of care coordination programs, efficient practices and procedures, and the value of the service from multiple stakeholder (e.g., provider, payer, patient, and caregiver) perspectives. Quantitative methods (e.g., surveys and reviews of medical and billing records) can provide important evidence of changes in participants' health, service utilization, and costs—as well as allowing for objective comparisons across program models. Qualitative methods (e.g., interviews and focus groups) are equally valuable to record implementation processes, document changes in quality of life and program perceptions that may not be quantifiable, and uncover unexpected outcomes.

Provide a sufficient description of services provided and contextual factors:

Provision of detailed information on service implementation, program design, and the existing service delivery system would facilitate enhanced understanding and replication of effective practices. Literature must include information on the program's institutional base, staffing, staff responsibilities, population characteristics, frequency and method of contact with patients, and services provided. Furthermore, the variability and success of care coordination programs are often related to the external service environment (e.g., health, psychosocial, and other concrete services available within the community). If needed services are absent, inaccessible, or of poor quality, the structural details of care coordination models are irrelevant. Consequently, evaluation findings must include a sufficient description of contextual factors.

The recommendations listed above were derived from a literature review conducted by the Social Work Leadership Institute (SWLI) and Center for Evaluation and Applied Research (CEAR) at The New York Academy of Medicine (NYAM) to identify outcomes and best practices of care coordination programs. The review was limited to articles reporting outcomes for programs providing both medical and psychosocial services to older adults with chronic conditions. Eighty-five articles published in peer-reviewed journals were identified for inclusion.¹³

Care coordination programs described in the literature were most commonly implemented by medical practices, health plans, senior centers, and government agencies; and provided some combination of needs assessments, individualized care management, mental health counseling, facilitated access to and coordination of medical and community-based social services and supports, discharge planning, medication management, health education, and caregiver support. A number of studies provided evidence for effectiveness, including improved utilization of health services, with reductions in emergency service use and overall costs.^14-21 Other, less commonly reported benefits included improved or stabilized mental health, physical and social functioning, and quality of life—as well as reductions in caregiver burden.^19-25 Qualitative methods—although less commonly utilized—were found to be invaluable for describing outcomes that were difficult to measure, and for describing the processes by which these outcomes were attained.¹³

Distinct gaps in published research were identified, which limit the relevance of findings for the many existing community-based programs that exist. Provider resources, priorities of researchers, and funding availability impact the scope and quality of the care coordination literature. To expand upon current research and address important gaps, multiple stakeholders must take efforts to employ flexible, yet comprehensive, research and evaluation methods in diverse settings. Providing further evidence on common models may inform and improve service delivery for large numbers of older adults.