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Medicine and Health Sciences Commons

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Electronic Theses and Dissertations

2022

Nursing

Care Coordination and Transition Care Management

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Bridging The Gaps: Exploring Factors Associated With Goal Achievement Within An Accountable Care Organization Care Coordination Program, Jessica L. Polk Jan 2022

Bridging The Gaps: Exploring Factors Associated With Goal Achievement Within An Accountable Care Organization Care Coordination Program, Jessica L. Polk

Electronic Theses and Dissertations

Background: Healthcare cost in the U.S. has been increasing at an unsustainable rate due to the growing population diagnosed with multiple chronic conditions and a fragmented healthcare system. The high-risk patient population includes persons who over utilize the healthcare system with frequent avoidable hospitalizations, emergency room visits, and exacerbations of their chronic conditions. This high-risk population makes up five percent of the U.S. but accounts for over fifty percent of all healthcare spending. Care coordination models have emerged to focus proactive health interventions for the highest-risk patient populations to reduce overutilization and empower patients to improve long-term health. Evidence has …