Abstract
Multimorbidity is ubiquitous in the geriatric population, with over half of older adults living with three or more chronic conditions.1 The health care of the frail elderly with multiple medical conditions is complex, fragmented, and expensive. In response to deficiencies in provision of health care, the Centers for Medicare and Medicaid Services has implemented the “triple aim” of (1) improving individual health, (2) improving population health, and (3) decreasing health care costs. Several different models of chronic care management, including disease management and care coordination,2–6 have been developed to meet this aim. Unfortunately, the data from initial clinical trials and demonstration projects have yet to provide convincing evidence that any one model (with the possible exception of collaborative management of depression)7,8 can achieve all three goals.
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