Abstract: The role of systems in addressing the needs of elderly and
chronically ill populations remains a far from universal way of thinking, much
less practice, in health care. Re-engineering the current fragmented system to
align providers, patients and payment models to facilitate proactive management
of conditions associated with advanced age and/or one or more chronic
diseases – rather than responding to costly consequences of a health care
system optimized for acute care conditions – will be a major challenge for all
stakeholders. There are, however, promising success stories that are taking
place in the United States today that may provide a model for improvement. The
authors define the issues faced by the health care providers and payers that
arise when providing care for the elderly and those with chronic conditions –
issues that threaten to overwhelm the financial and human health care resources
that exist to serve these populations. They define innovative ways of thinking
about systems of care, and provide examples of unique systems that have applied
theory into practice. These successful leaders may offer lessons in proactively
managing complex health conditions, overcoming communication barriers and using
technology to complement the necessary human touch that is essential to health
care delivery.