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Related Experiment Videos

Managing elders with comorbidities.

Cheryl Schraeder1, Donna Dworak, John F Stoll

  • 1Health Systems Research Center, Carle Foundation Hospital, Urbana, Illinois 62853, USA. Cheryl.Schraeder@Carle.com

The Journal of Ambulatory Care Management
|June 22, 2005
PubMed
Summary

This study evaluates a Medicare Coordinated Care Demonstration program for elderly patients with chronic conditions. The intervention, based on the chronic care model, involves primary care teams and patient-centered care.

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Area of Science:

  • Gerontology
  • Health Services Research
  • Chronic Disease Management

Background:

  • Elderly populations face complex health challenges with multiple chronic conditions.
  • Effective disease management programs are crucial for improving health outcomes and reducing healthcare costs in older adults.
  • The chronic care model provides a framework for organizing healthcare to better meet the needs of patients with chronic illnesses.

Purpose of the Study:

  • To describe the interventional components of Carle's Medicare Coordinated Care Demonstration.
  • To outline the structure and patient population of this care/disease management program.
  • To detail the multidisciplinary primary care team composition and patient-centered approach.

Main Methods:

  • Prospective, longitudinal randomized treatment-control design.

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  • Intervention focused on elderly patients in 13 Illinois counties.
  • Inclusion criteria: diagnoses of COPD, CAD, diabetes, atrial fibrillation, or CHF.
  • Primary care teams included physicians, advanced practice nurses, nurse case managers, and case assistants.

    • Main Results:

    • The program integrated components of the chronic care model for managing multiple chronic conditions.
    • Patient and family engagement were central to the intervention's design.
    • A randomized controlled trial methodology was employed for evaluation.

    Conclusions:

    • The Medicare Coordinated Care Demonstration utilizes a comprehensive, team-based approach to chronic disease management.
    • The patient-centered intervention aims to improve care for elderly individuals with prevalent chronic conditions.
    • The study's design allows for rigorous evaluation of the program's effectiveness.