Physician, Nurse, and Social Worker Collaboration in Primary Care for Chronically Ill Seniors

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Abstract
ALTHOUGH MEDICARE funds a vast array of health services for elderly and disabled persons, the coordinated delivery of these services remains a challenge. Moreover, it has lacked preventive services explicitly geared to reducing hospitalizations and premature admissions to nursing homes.1-3 To correct such deficits, the social health maintenance organizations (HMOs) of the 1980s linked the HMO concept with case management and long-term care services for seniors. Unfortunately, they failed to achieve cost savings and improve care outcomes. The lack of strong physician involvement in treating high-risk patients and communicating regularly with case managers was seen as part of the problem.4,5