248021 Effective Community-based Care Management Model for Chronically Ill Older Adults: An Eight Year Randomized Trial

Tuesday, November 1, 2011

Kenneth Coburn, MD, MPH , Health Quality Partners, Doylestown, PA
A unique community-based nurse care management model designed to improve the health of chronically ill older adults has been evaluated in the Medicare Coordinated Care Demonstration (MCCD) administered by the Center for Medicare and Medicaid Services (CMS) by means of a randomized controlled trial for more than eight years. Of 15 programs evaluated nationwide within the MCCD, the model developed by Health Quality Partners is the only one that CMS continues to evaluate. The guiding design principle of the model is to identify and incorporate several preventive interventions with strong evidence of effectiveness into an easily accessible program provided by a nurse care manager on a continuous, long-term basis. Lifestyle behavior interventions, gait and balance training, self-management skill building, and ongoing monitoring and assessment are components of the program. The model is community-based, working in collaboration with primary care and hospital providers. Key attributes of the model include; 1. A learning management system to ensure services and protocols are delivered according to standards, 2. A broad range of preventive services (including group programs) delivered directly by the nurses, 3. Frequent participant contacts (mean=17.5/year) with a high proportion (62%) being in person. The model is associated with a 26% decrease in all-cause mortality (p=0.04). Among participants with heart failure, coronary heart disease, diabetes, or COPD and a recent hospital admission, the program is associated with 33.4 fewer hospitalizations per 100 patient-years (p<0.01) and a $487 per person per month reduction in Medicare Part A & B expenditures (p=0.01).

Learning Areas:
Administer health education strategies, interventions and programs
Chronic disease management and prevention
Program planning
Public health or related nursing

Learning Objectives:
1. Describe an effective model of community-based care management for chronically ill older adults 2. List key attributes of an effective model of community-based chronic care management 3. Evaluate the impacts of such a program on health outcomes, hospitalizations, and Part A & B Medicare expenditures

Keywords: Chronic Diseases, Community Health Programs

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I have had the overall responsibility for the design, implementation, and ongoing conduct of the Health Quality Partners Community-based Advanced Care Management program within the Medicare Coordinated Care Demonstration.
Any relevant financial relationships? Yes

Name of Organization Clinical/Research Area Type of relationship
Health Quality Partners CEO and Medical Director Employment (includes retainer)

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.