Carol V. O'Shaughnessy, MA
Many patients with complex chronic illnesses and/or functional impairments face not only managing the medical care necessitated by their conditions, but also finding ways to access supportive services that help them live independently in their homes and communities. Access to supportive services can be difficult for anyone with complex conditions, and social and economic patient characteristics can complicate the task. The absence or insufficiency of home care support; assistance in hospital-to-home transitions; follow-up medical coaching; and access to transportation for medical appointments, adequate nutrition, and mental or behavioral health services act as barriers to positive health care outcomes. Theoretically, models of care, such as health homes, that aim to improve outcomes for people with complex chronic conditions may help fill these gaps. But how far these initiatives will go beyond the traditional medical model of care remains to be determined. This Forum session, a continuation of the Forum’s programming on serving populations with complex conditions, explored barriers to effective coordination of social support and health care services and discussed opportunities for service integration.
Robert Wood Johnson Foundation, "Health Care’s Blind Side: The Overlooked Connection between Social Needs and Good Health," December 2011.
See also "Preventing Hospital Readmissions: How Can Care Transitions for Medicare Beneficiaries Be Improved?" (Forum Session, October 28, 2011).