Just how hard is it to keep elderly, chronically ill patients out of the hospital? According to a recent study, published in this week’s JAMA, it is somewhat difficult. A study detailing the interventions of “care coordination” via a consortium of 15 healthcare venues (including facilities such as long term care and tertiary care institutions) shows that efforts by care teams to keep patients out of the hospital (a proxy metric for fewer Medicare claims) came up extremely short. In spite of streamlined communication between physicians, home nursing programs, ambulatory care centers, and other care entities; the effort to apply an efficient model of care coordination following relapses in certain chronic conditions was cost-neutral in the best of circumstances. The implications are mainly cautious ones for the interests of many healthcare policy makers who are invested in the medical home concept of care coordination for paitents with many chronic conditions. For the pragmatists in us, the drive for change may rest in changing the rigidly inert practice habits of physicians in a managed care marketplace which continues to reward “efficiency” of healthcare delivery based upon the sheer numbers of patients seen in any given period.

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