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HCM 340 Milestone One

Danitza Fernandez-Andes

Southern New Hampshire University

Health Care Delivery System

Dr.Dalona Griffin

May 24, 2026 HCM 340 Milestone One

Introduction

This paper examines a gap in quality related to care coordination for individuals with chronic illnesses. It will describe the specific gap and the affected population, briefly outline the history of the issue, explain the impact of socioeconomic background, describe how the gap affects healthcare delivery, and predict potential implications if the gap is not addressed. Care coordination fragmentation remains a persistent quality issue in U.S. healthcare, particularly for adults managing multiple chronic conditions.

Gap

A major gap in the delivery of healthcare exists in the fragmentation of care coordination for individuals with chronic illnesses. This gap primarily affects adults with multiple chronic conditions (MCC), such as diabetes, heart disease, and arthritis (Joo, 2023). Fragmented care occurs when patients receive services from multiple providers with poor communication and a lack of integrated care planning, resulting in disjointed treatment. This leads to poorer patient outcomes compared to well-coordinated care. Adults with chronic illnesses are particularly vulnerable because their conditions require ongoing management across specialties, yet the healthcare system often fails to provide seamless coordination (Joo, 2023).

History

The gap in care coordination for people with chronic illnesses is a longstanding structural issue rather than a recent development. The U.S. healthcare system was originally designed to address acute, short-term conditions. Over decades of policy reforms, this misalignment has persisted despite various attempts at improvement (Bierman et al., 2021). The Agency for Healthcare Research and Quality (AHRQ) has recognized these ongoing failures in caring for individuals with multiple chronic conditions, highlighting that the problem has deep roots in the historical structure of care delivery (Bierman et al., 2021).

Socioeconomic Background

Socioeconomic background significantly impacts access to coordinated care for individuals with chronic illnesses. Low-income and safety-net populations face additional barriers such as low health literacy, transportation difficulties, language barriers, and limited access to specialists. These challenges make care coordination even more difficult and worsen health outcomes (Nguyen et al., 2021). Lower socioeconomic status often means reliance on under-resourced safety-net systems, where structural inequities compound the effects of fragmented care. Individuals with higher socioeconomic resources are better able to navigate the system or access supplementary support (Nguyen et al., 2021).

Affected

The gap in care coordination negatively affects the healthcare delivered to individuals with chronic illnesses. Fragmentation is associated with higher rates of emergency department visits, avoidable hospitalizations, uncontrolled symptoms, medication errors, increased diagnostic testing, and diminished patient functioning (Joo, 2023; McMenamin et al., 2023). Without effective coordination, patients experience duplicated efforts, gaps in communication among providers, and suboptimal management of their conditions. Models that emphasize team-based and nurse practitioner-led coordinated care have shown better outcomes, underscoring the current deficiencies in standard delivery (McMenamin et al., 2023).

Implications

If this gap in care coordination is not addressed, several serious implications are likely. Patients will continue to face fragmented, duplicated, and burdensome healthcare experiences, leading to preventable adverse events, increased caregiver fatigue, and escalating healthcare costs (Watson et al., 2024). Broader effects may include higher overall system strain, reduced quality of life for those with chronic illnesses, and continued inefficiencies. Without systemic changes toward person-centered and coordinated care planning, these issues will persist and potentially worsen as the population with multiple chronic conditions grows (Watson et al., 2024).

References

Bierman, A. S., Wang, J., O’Malley, P. G., & Moss, D. K. (2021). Transforming care for people with multiple chronic conditions: Agency for Healthcare Research and Quality’s research agenda. Health Services Research, 56(1), 973–979. https://doi.org/10.1111/1475-6773.13863

Joo, J. Y. (2023). Fragmented care and chronic illness patient outcomes: A systematic review. Nursing Open, 10(6), 3460–3473. https://doi.org/10.1002/nop2.1607

McMenamin, A., Turi, E., Schlak, A. E., & Poghosyan, L. (2023). A systematic review of outcomes related to nurse practitioner-delivered primary care for multiple chronic conditions. Medical Care Research and Review, 80(6), 563–581. https://doi.org/10.1177/10775587231186720

Nguyen, K. H., Fields, J. D., Cemballi, A. G., Desai, R., Gopalan, A., Cruz, T., Shah, A., Akom, A., Brown, W., Sarkar, U., & Lyles, C. R. (2021). The role of community-based organizations in improving chronic care for safety-net populations. The Journal of the American Board of Family Medicine, 34(4), 698–708. https://doi.org/10.3122/jabfm.2021.04.200591

Watson, B. N., Estenson, L., Eden, A. R., Gerstein, M. T., Carney, M. T., Dotson, V. M., Milnes, T., & Bierman, A. S. (2024). Person-centered care planning for people living with or at risk for multiple chronic conditions. JAMA Network Open, 7(10), Article e2439851. https://doi.org/10.1001/jamanetworkopen.2024.39851

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HCM 340 Milestone Two

Danitza Fernandez-Andes

Southern New Hampshire University

Health Care Delivery System

Dr. Dalona Griffin

May 24, 2026

Existing Initiative

This paper analyzes the Centers for Disease Control and Prevention’s (CDC) 6|18 Initiative as the selected healthcare initiative to address the gap in care coordination for individuals with multiple chronic conditions (MCC). The 6|18 Initiative promotes evidence-based interventions for high-burden conditions common in MCC patients, such as diabetes and high blood pressure. This analysis will cover how the initiative addresses the gap, its specific goals, development circumstances, required resources, and why it requires further improvement.

Address Gap

The 6|18 Initiative was developed to tackle fragmentation in care coordination by fostering stronger collaboration between public health agencies, payers, and providers. For adults with MCC, fragmented care often results in poor communication among specialists, duplicated services, and gaps in ongoing management. The initiative addresses this by encouraging integrated approaches, such as team-based care, improved data sharing, and community-clinical linkages for conditions like type 2 diabetes and hypertension. These efforts help reduce disjointed treatment and support more seamless care planning, aligning with findings that coordinated models improve outcomes for MCC patients (Joo, 2023; McMenamin et al., 2023).

Goals

The specific goals of the 6|18 Initiative focus on improving health outcomes and controlling costs through the rapid adoption of 18 evidence-based interventions targeting six high-burden conditions. Key priorities include increasing coverage and utilization of preventive services, enhancing partnerships across sectors, and promoting interventions that support better chronic disease management. For care coordination gaps, it aims to strengthen team-based approaches and linkages between clinical providers and community resources, ultimately reducing emergency visits and hospitalizations while advancing more patient-centered, integrated care for those with MCC (Centers for Disease Control and Prevention, n.d.).

Development

The 6|18 Initiative was launched around 2016 in response to the transforming U.S. healthcare landscape, including the expansion of insurance coverage and a shift toward value-based care. Factors considered during development included the high prevalence and costs of chronic conditions, the need for stronger public health-healthcare collaboration, and evidence from sources like the Community Guide and U.S. Preventive Services Task Force. CDC selected conditions and interventions based on their potential for short-term impact on health and costs, addressing longstanding structural issues in care delivery for MCC populations (Bierman et al., 2021; Centers for Disease Control and Prevention, n.d.). This initiative emerged amid growing recognition that traditional acute-care models were insufficient for the rising number of adults with multiple chronic illnesses. By focusing on cross-sector partnerships, it sought to bridge gaps between siloed providers and support more coordinated systems.

Resources

Implementing the 6|18 Initiative relies on a combination of CDC programmatic support, state and local public health funding, and partnerships with payers like Medicaid. While CDC does not provide direct implementation grants specifically for this initiative, it leverages existing cooperative agreements and technical assistance. Additional support has come from foundations such as the Robert Wood Johnson Foundation, which funded resource centers for technical assistance to states. Resources also include staff expertise in evidence synthesis, evaluation tools, and collaboration frameworks to help states integrate interventions into existing budgets and delivery systems.

Improvement

Although the 6|18 Initiative has made progress in promoting evidence-based practices, it is not fully meeting its intended purpose due to challenges in widespread adoption and sustainability. Barriers such as varying state capacities, payment policy limitations, and difficulties in scaling partnerships have slowed full integration into routine care coordination for MCC patients. As a result, fragmented care persists in many settings, leading to continued inefficiencies and suboptimal outcomes (Watson et al., 2024). Improvement is needed through expanded technical support, better alignment with value-based payment models, and stronger data systems to track long-term impacts on care coordination.

References

Bierman, A. S., Wang, J., O’Malley, P. G., & Moss, D. K. (2021). Transforming care for people with multiple chronic conditions: Agency for Healthcare Research and Quality’s research agenda. Health Services Research, 56(1), 973–979. https://doi.org/10.1111/1475-6773.13863

Centers for Disease Control and Prevention. (n.d.). CDC’s 6|18 Initiative: Accelerating evidence into action. https://www.cdc.gov/sixeighteen/

Joo, J. Y. (2023). Fragmented care and chronic illness patient outcomes: A systematic review. Nursing Open, 10(6), 3460–3473. https://doi.org/10.1002/nop2.1607

McMenamin, A., Turi, E., Schlak, A. E., & Poghosyan, L. (2023). A systematic review of outcomes related to nurse practitioner-delivered primary care for multiple chronic conditions. Medical Care Research and Review, 80(6), 563–581. https://doi.org/10.1177/10775587231186720

Watson, B. N., Estenson, L., Eden, A. R., Gerstein, M. T., Carney, M. T., Dotson, V. M., Milnes, T., & Bierman, A. S. (2024). Person-centered care planning for people living with or at risk for multiple chronic conditions. JAMA Network Open, 7(10), Article e2439851. https://doi.org/10.1001/jamanetworkopen.2024.39851

HCM 340 Annotated Bibliography

Danitza Fernandez-Andes

Southern New Hampshire University

Health Care Delivery System

Dr.Dalona Griffin

May 19, 2026

Annotated Bibliography

Option One: A gap in quality related to care coordination for individuals with chronic illnesses

I: Describe a specific gap in the delivery of healthcare. Include the specific population affected by the gap.

I. Fragmented care and chronic illness patient outcomes: A systematic review.

a. Joo, J. Y. (2023). Fragmented Care and Chronic Illness Patient outcomes: A systematic Review. Nursing Open, 10(6), 3460–3473. https://doi.org/10.1002/nop2.1607

b. This systematic review investigated 10 U.S. studies to understand the association between fragmented care and patient outcomes among adults with chronic disease. The review identified strong links between the fragmentation of care and higher rates of emergency department visits, more diagnostic testing, and higher healthcare costs. Overall, the researchers discovered that fragmented care is a measurable and chronic quality-of-care concern, especially for those with diabetes, heart disease and arthritis.

c. This source is relevant as it clearly states that care coordination fragmentation is a gap in the delivery of health care and that adults with chronic illnesses are the target population. The systematic review design adds to the credibility of the findings, and offers a wide range of evidence-based documentation of the negative effects of poor coordination on chronically ill patients in multiple care settings in the United States.

II. Briefly describe the history of this gap in access to healthcare. Has this been an issue historically, or is it a modern issue?

I. Transforming care for people with multiple chronic conditions: Agency for Healthcare Research and Quality's research agenda.

a. Bierman, A. S., Wang, J., O’Malley, P. G., & Moss, D. K. (2021). Transforming care for people with multiple chronic conditions: Agency for Healthcare Research and Quality’s research agenda. Health Services Research, 56(1), 973–979. https://doi.org/10.1111/1475-6773.13863.

b. The article presents a formal research agenda from the federal government to tackle care failures among individuals with multiple chronic conditions (MCC). As the authors record, the healthcare system was built to address acute, one-time conditions and has consistently failed to be aligned with patients' needs when they require and benefit from continual, coordinated care. They attribute this misalignment to the decades of policy reform, where gaps have remained in spite of various interventions.

c. This source is relevant as it provides evidence that the issue of care coordination failures for chronically ill patients is an entrenched and longstanding structural issue, not new or emerging. The article presents a federally sponsored research agenda, which serves as authoritative historical background and is very relevant to understanding the history of the problem, because it indicates that the U.S. health system has long recognized this problem, though it has not been fully solved.

III. Explain the impact that the socioeconomic background of the population has on their access to healthcare.

I. Illuminating the Role of Community-Based Organizations to Improve Chronic Care for Safety-Net Populations.

a. Nguyen, K. H., Fields, J. D., Cemballi, A. G., Desai, R., Gopalan, A., Cruz, T., Shah, A., Akom, A., Brown, W., Sarkar, U., & Lyles, C. R. (2021). The Role of Community-Based Organizations in Improving Chronic Care for Safety-Net Populations. The Journal of the American Board of Family Medicine, 34(4), 698–708. https://doi.org/10.3122/jabfm.2021.04.200591.

b. This article examines the role of a health care system in working with community-based organizations to manage the chronic disease burden among low-income, safety-net populations. The authors apply qualitative data gathered from the San Francisco Health Network and describe the ways in which individuals with lower SES face multiple layers of problems in coordinating chronic care, e.g., low health literacy, transportation difficulties, language barriers, and specialist access. The study highlights the ways that structural inequities have a way of making care coordination outcomes worse for these populations.

c. This is relevant to the topic as it documents and describes the barriers to access and coordination of care that exist and are related to socio-economic factors. It provides evidence that poor management of chronic diseases is experienced by low-income populations in safety net systems, and that there is a direct link between low income and poor experiences in the management of chronic diseases.?

IV: Describe how the healthcare delivered to the population is affected by the gap in access.

I. A Systematic Review of Outcomes Related to Nurse Practitioner-Delivered Primary Care for Multiple Chronic Conditions.

a. McMenamin, A., Turi, E., Schlak, A. E., & Poghosyan, L. (2023). A systematic review of outcomes related to nurse practitioner-delivered primary care for multiple chronic conditions. Medical Care Research and Review, 80(6), 563–581. https://doi.org/10.1177/10775587231186720.

b. This systematic review reviews the impact of different primary care delivery models on health outcomes for people with multiple chronic conditions. The authors conclude that care fragmentation, which involves limited communication among providers as well as a lack of coordinated care planning, is always associated with avoidable hospitalizations, uncontrolled symptoms, medication mistakes and diminished patient functioning. The review notes that team-based, coordinated primary care, including nurse practitioner models of care, is linked to improved outcomes with integration ongoing.

c. It is very relevant to the topic because it shows clearly, in clinical terms, the impact that a lack of coordinated care has on the quality of care that is provided for patients with chronic conditions. These documented findings, including: higher hospitalization rates and suboptimal symptom control, shed light on the day-to-day realities of poor care co-ordination for patients with chronically ill patients.

V: Predict any potential implications if this gap in a is not addressed.

I. Person-Centered Care Planning for People Living With or at Risk for Multiple Chronic Conditions

a. Watson, B. N., Estenson, L., Eden, A. R., Gerstein, M. T., Carney, M. T., Dotson, V. M., Milnes, T., & Bierman, A. S. (2024). Person-Centered Care Planning for People Living With or at Risk for Multiple Chronic Conditions. JAMA Network Open, 7(10), e2439851–e2439851. https://doi.org/10.1001/jamanetworkopen.2024.39851.

b. This qualitative study relies on insights from the stakeholders gathered through a 2022 AHRQ Request for Information on person-centered care planning for multiple chronic conditions. The authors describe nine of the key themes and also concur that, in the absence of structural change in health care coordination, each patient will continue to experience fragmented, duplicated, and burdensome health care. The study highlights the increasing risks of preventable adverse events, caregiver fatigue, and escalating costs in the health care system if care planning is not person-centered and coordinated.

c. This source is directly relevant to the topic, predicting the consequences should care coordination gaps continue. The article presents a stakeholder-driven prediction of the issues the health care system and the chronically ill population will face if coordination issues are not addressed in a systematic fashion, making it a useful resource for the prediction of future implications.