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

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).