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Addressing these barriers requires a multi-pronged strategy that relies on better knowledge, tools, and incentives. For each of these strategies, our recommendations are aimed at providers, family caregivers, and patients—who can play a critical role in managing their own care. Key recommendations for improving coordination of care for people with chronic disease include:

• More testing of care delivery models (for example, medical homes and accountable care organizations) to find out what works.
• Rapid adoption of those models that work. Models that provide care during transitions between hospitals and other settings have proven to improve care, reduce rehospitalizations, and show a positive return on their cost, and should be adopted.
• Incorporating best practices into clinical preparation and training for providers.
• Engaging patients with chronic conditions who are able to participate in their care, providing them with tools to empower their conditions.
• Supporting and engaging family caregivers.
• Encouraging wise use of pharmaceuticals, including making medication more affordable.
• Improving coordination of care through adoption of health information technology and improving incentives through changes in payment policy.
• Ensuring an adequate workforce, including making the most of the workforce we have.

AARP commends the committee for recognizing the necessity of improving quality and efficiency in health care, focusing on outcomes of care, and addressing the challenge of quality improvement by integrating quality improvement and patient safety training into the clinical training of health professionals. Quality and safety problems in the U.S. pervade our health care system. We are gratified to see the growing determination of all sectors to attain greater value from the health system so that organizations deliver high quality, efficient, safe care and engaged patients make informed health decisions that reflect their values and preferences. We are convinced that better quality will lead to a more affordable, sustainable system. To accomplish this, we need better information to support clinical and patient decisions, enabled by the appropriate use of health information technology; and aligned incentives (for providers and patients) to encourage coordinated, patient-centered care that ensures patients the care they need when they need it.

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