This is a great paper to read, it illustrates a model that embraces all the different needs of patients such as medical, psychological, and social. This model is already being used by different States (CMS) in the structure of the Health Home, which primary goal is to provide comprehensive care coordination to people with multiple chronic conditions, high hospital utilizations (not having an assigned medical home provider) mental health needs, drug and substance abuse, plus social determinants of health such as housing, access to food, employment, etc. Care coordination is a necessary, not just the right thing to do, unfortunately reimbursement is not yet being taking into account by CMS, which hinders practices to provide comprehensive care coordination services to those that are most needed. However, we know that there are some new initiatives around care coordination with some payment incentives, the Health Home being on of them, which still in the infancy stages, but some progress is being made.
Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs