Longitudinal Evaluation of Care Management for Elderly Patients with Comorbidities

This is a prospective, randomized clinical trial testing a coordinated care model on its ability to improve self management behaviors, clinical health, satisfaction and use of Medicare covered services. The intervention, based on the core components of the Chronic Care Model, provides care and disease management services to elderly patients from primary care teams. The study sample consists of 2,301 individuals who enrolled between April, 2002 and April, 2003 (control group = 1,140; intervention group = 1,161). Outcomes will be presented at 36 and 48 months post enrollment and were collected from patient self-report, electronic laboratory results, medical record review and Medicare claims. At the end of 36 months there were significant differences between the intervention and control groups. Intervention patients had higher satisfaction scores, patients with diabetes reported higher rates of annual foot exams and patients with CHF reported higher rates of daily weighing. Intervention patients had higher rates of lipids testing and blood pressure control. These results are similar at 48 months with more than 62% of the study population reporting outcomes. Results will also be presented on hospitalizations and Medicare costs for the first 36 months of program operation. Nurse case manager time and related activities will be discussed for the intervention group. These findings indicate promising results can be achieved when nurses work in partnership with primary care physicians using care/disease management interventions to manage elderly paitents with comorbidities. They also underscore the unique challenges effective interventions face with this patient population.