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Elderly/Long-Term Care

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Postdischarge care management that integrates medical and social care can improve outcomes of the low-income elderly

Care management that integrates medical and social care can improve the outcomes of chronically ill and functionally impaired low-income elderly patients recently discharged from the hospital, according to a pilot care management program that was developed for a Medicare Advantage HMO population. These are patients who are at high risk of being rehospitalized or placed in a nursing home.

The pilot program has led to the development of an ongoing randomized controlled trial—After Discharge Care Management of Low-Income Frail Elderly (AD-LIFE)—a larger trial in which the subjects' insurance coverage includes traditional Medicare, Medicaid, and/or Medicare Advantage. Both the pilot study and the AD-LIFE trial use a hospital-based interdisciplinary team, comprehensive geriatric assessment, and care management by a team nurse.

The nurse works collaboratively with the local Agency of Aging social services program through the patient's first year after hospital discharge. The programs include comprehensive (hospital and home) assessment, patient goal setting, development of patient self-care skills, and care planning for chronic illnesses and geriatric syndromes (including incontinence, depression, nutrition and skin problems, and memory impairment).

The interdisciplinary team has access to medical specialists and the patient's primary care doctor, does frequent followup evaluations, and revises care plans as needed.

An estimated 92 percent of the 118 Medicare/Medicaid-insured elderly patients enrolled in the care management pilot program had at least 1 medical or social problem requiring intervention. Half of these patients were taking 5 to 10 prescription drugs, 40 percent were living alone, 28 percent had congestive heart failure, 28 percent had diabetes, and many were unable to perform some activity of daily living or suffered from geriatric syndromes. About 70 percent of the patients said the care management program improved their health, made it easier to get health care services, and provided them with a better understanding of their disease.

Program implementation was also associated with decreased hospital admissions and care costs with savings of approximately $1,000 per patient per month. Funding for the 3-year AD-LIFE trial is supported in part by the Agency for Healthcare Research and Quality (HS14539).

See "The AD-LIFE trial," by Kathy Wright, M.S.N., R.N., A.P.N., B.C., Susan Hazelett, R.N., M.S., David Jarjoura, Ph.D., and Kyle Allen, D.O., in the May 2007 Home Healthcare Nurse 25(5), pp. 308-314.


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