HCM 340 Final Project
Juaniita Onasanya
HCM 340
Victoria Mills
October 3, 2025
, Introduction
The U.S. healthcare delivery system has faced ongoing challenges in providing equitable
and quality care, particularly for individuals with chronic illnesses. This population often
experiences fragmented care, leading to poor health outcomes and increased healthcare costs.
Chronic illnesses such as diabetes, heart disease, and asthma require continuous management and
coordination among various healthcare providers. Despite numerous initiatives aimed at
improving care coordination, significant gaps remain, particularly in access to integrated services
that address the unique needs of these patients (Mills, 2023).
Historically, the gap in care coordination for individuals with chronic illnesses has roots
in the traditional fee-for-service model, which incentivizes quantity over quality of care. This
model often results in siloed care, where providers do not communicate effectively, leading to
duplicate tests, conflicting treatment plans, and ultimately, patient dissatisfaction (Bodenheimer
& Pham, 2010). The socioeconomic background of this population further complicates access to
care, as individuals from lower-income brackets may lack transportation, face language barriers,
or experience other systemic obstacles that hinder their ability to receive timely and appropriate
care (Berkowitz, 2016).
The impact of these gaps is profound. Patients with chronic illnesses who do not receive
coordinated care are at higher risk for hospital readmissions, emergency room visits, and overall
worse health outcomes. If these gaps are not addressed, the implications could include escalating
healthcare costs, increased morbidity and mortality rates, and a further erosion of trust in the
healthcare system among vulnerable populations (Bodenheimer & Pham, 2010).
Initiative
To address the gap in care coordination for individuals with chronic illnesses, the
Accountable Care Organization (ACO) model was developed. ACOs are designed to improve the
Juaniita Onasanya
HCM 340
Victoria Mills
October 3, 2025
, Introduction
The U.S. healthcare delivery system has faced ongoing challenges in providing equitable
and quality care, particularly for individuals with chronic illnesses. This population often
experiences fragmented care, leading to poor health outcomes and increased healthcare costs.
Chronic illnesses such as diabetes, heart disease, and asthma require continuous management and
coordination among various healthcare providers. Despite numerous initiatives aimed at
improving care coordination, significant gaps remain, particularly in access to integrated services
that address the unique needs of these patients (Mills, 2023).
Historically, the gap in care coordination for individuals with chronic illnesses has roots
in the traditional fee-for-service model, which incentivizes quantity over quality of care. This
model often results in siloed care, where providers do not communicate effectively, leading to
duplicate tests, conflicting treatment plans, and ultimately, patient dissatisfaction (Bodenheimer
& Pham, 2010). The socioeconomic background of this population further complicates access to
care, as individuals from lower-income brackets may lack transportation, face language barriers,
or experience other systemic obstacles that hinder their ability to receive timely and appropriate
care (Berkowitz, 2016).
The impact of these gaps is profound. Patients with chronic illnesses who do not receive
coordinated care are at higher risk for hospital readmissions, emergency room visits, and overall
worse health outcomes. If these gaps are not addressed, the implications could include escalating
healthcare costs, increased morbidity and mortality rates, and a further erosion of trust in the
healthcare system among vulnerable populations (Bodenheimer & Pham, 2010).
Initiative
To address the gap in care coordination for individuals with chronic illnesses, the
Accountable Care Organization (ACO) model was developed. ACOs are designed to improve the
