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Reply by author Jean Scholz Mellum to Lisa Palucci on “Registered Nurse Care Coordination: Creating a Preferred Future for Older Adults with Multimorbidity”

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February 20, 2019

Response by author Jean Scholz Mellum to Lisa Palucci on “Registered Nurse Care Coordination: Creating a Preferred Future for Older Adults with Multimorbidity” (September 30, 2015)

Dear Editor,

Thank you for giving us the opportunity to respond to the letter to the editor written by Lisa Palucci. We are pleased to see her interest in older adults with multimorbidity and advancing models of care and care coordination for this growing population group.

Since this article was published, there has been a growth in the development of care coordination programs across the country. After additional research on care coordination programs (CCPs) and older adults’ experience with CCPs, several features commonly associated with successful care coordination programs have emerged from the literature. As summarized in a more recent article, the features of successful CCPs include face-to-face patient contact; physician engagement and cooperation; patient education; a communications hub among care coordination team members and primary care physicians; transition management when the patient leaves the hospital; and teaching patients about medication management. Other characteristics of successful CCPs identified from the literature include deliberate governance structures, strong leadership support for the program, and trusting relationships among multidisciplinary team members (Scholz Mellum, Martsolf, Glazer, Martsolf, & Tobias, 2018).

From further examination of the literature, and after having conducted studies to gain a deeper understanding of older adults’ experience with CCPs, this author has theorized that there should be a focal shift. This shift should be from providers and the economics associated with care coordination to a focus on the individual needs of older adults. To individualize care coordination services, an assessment is needed of three abilities of older adults including their cognitive functioning, physical functioning, and psychosocial resources. Psychosocial resources include, but are not limited, to an older adult’s personal strengths; family and significant other support; health system support and availability of services; and economic resources, including financial well-being and type of insurance. By building upon older adults’ psychosocial resources, or helping older adults with what they lack, issues of health disparities and inequities, as suggested in the letter to the editor, can be addressed in specific ways to meet their unique needs.

Patient-centered care does not occur without the identification of the specific needs of individuals. When patient-centered care does occur, it will likely lead to increased engagement in care and increased self-management of chronic illnesses (Mellum, Martsolf, Glazer, Tobias, & Martsolf, in press). Furthermore, without the partnership between provider and patient which generally occurs with patient-centered care, effectiveness and efficiency is lost and Triple Aim outcomes may not be met. Assessment of individual specific needs related to cognitive status, functional status, and psychosocial resources/needs will most likely decrease health disparities and inequities across a population. This type of individualized care is theorized to be care that is efficient and cost-effective over time and across all settings.

Models of care coordination that serve individuals specific needs will probably work in a variety of populations and in urban as well as rural settings. Yet it may be challenging to achieve economies of scale in areas with small numbers of older adults with multimorbidity. The infrastructure costs of developing and operating a CCP may exceed the capital or financial resources of an area. In those situations, it is important for nursing leadership to identify partners for collaboration. In some locales, these types of collaborations have led to Accountable Care Organizations (ACOs), or partnerships to create value for payers and patients by coordinating care and managing overall costs and health outcomes associated with the care for individuals within that population. Nurse leaders from across the country have started ACOs or have been intimately involved with them. It seems that ACOs with strong nursing input are the most holistic and will have sustainability because they meet the many issues associated with the unique needs of each multimorbid older adult.

Be Well,

Jean Scholz Mellum, Ph.D., RN, NEA-BC
Capital University
Columbus, OH 43209


Scholz Mellum, J., Martsolf, D., Glazer, G., Martsolf, G., & Tobias, B. (2018). A mixed methods study of the experience of older adults with multimorbidity in a Care Coordination Program. International Journal of Care Coordination, 21(1-2), 36-46.

Mellum, J. S., Martsolf, D. S., Glazer, G., Tobias, B., & Martsolf, G. (in press). How older adults with multimorbidity manage their own care within a formal care coordination program? Geriatric Nursing. doi: 10.1016/j.gerinurse.2018.06.006