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The Play of Chance May, in Some Contexts, Be Consistent

and coordination of care between providers. Changes are not without (financial) risks and will only be implemented when, at the level of organizations and groups or teams, change will lead to (perceived) benefits. Protocols and working patterns of teams might have to change. Interventions to coordinate care often consist of activities on top of regular care, which makes the system even more complex, with more caregivers busy informing each other. New ways forward might have to be sought—ways in which additional caregivers are not relied on to coordinate care, but instead communication is improved within the system. The Independence at Home (IAH) concept consists of mobile teams of primary medical, nursing, and social work staff who deliver comprehensive primary care to the individual at home. IAH teams replace office-based providers for the small subgroup of ill elderly adults who are poorly served in the office setting. The teams offer access to care for sick homebound individuals who have little or inadequate ongoing primary medical care because of their immobility. This model of home-based primary care led to 17% lower total Medicare costs over a mean 2 years of follow-up, with similar mortality in the group that received home-based primary care and the control group. Another way is to expand the reach of the primary care physician (PCP) by using his or her connection with community nurses. One-third of frail older adults receive help with activities of daily living. In this case, the community nurse who visits individuals regularly in their homes might be able to monitor their health and discuss changes with the PCP. The nurse has many possibilities to gain the trust of clients and their social networks to change lifestyles. The education level of the nurse might need to be high to have good judgment of the risk of health deterioration, to convince clients and their social networks to improve self-management, adherence to medications and a healthy lifestyle, and to have a good relationship with the PCP (including adequate advising and answering questions). With the rise of the popularity of the medical home, the possibilities of care coordination by nurse and PCP within their regular working schedule might increase in the future. In the Netherlands, the fast-growing company Buurtzorg works successfully with a model of self-managed teams, with high satisfaction levels of nurses, clients, and PCPs. To increase the probability of success, blending payment of Medicaid and Medicare is recommended. States have limited (financial) incentives to invest in a more-generous Medicaid policy and integrate care for people with chronic diseases with long-term care.