AHRQ Innovators Exchange features information and a video about a pilot study to improve care for low-income elderly patients with chronic illnesses.
Conducted by Ohio-based Summa Care under the leadership of Practice Change Fellows and Advisory Board Member Kyle Allen, DO, AGSF, the project reports that 70% of participants reported improved health, and 93% rated their experience as good or excellent one year after participation. The program led to cost savings of approximately $600 to $1000 per patient per month as a result of decreased hospitalizations. Summa Health is now conducting a three-year randomized controlled trial to confirm these results.
Summa Health System developed a program called the Frail Elders Care Management Program. The project involved interdisciplinary teams that provide integrated medical and social care management to low-income elderly in-patients who have chronic illnesses. The program aimed to ease the transition from hospital to home, provide preventive care, identify new and emerging problems, reduce readmissions, and prevent functional decline. Most participants were over the age of 65, had several chronic conditions and impaired activities of daily living, and had one or more problems that required an intervention. For example, nearly 40% of patients took more than 10 prescriptions, and nearly 50% had experienced one or more falls.
The project featured an interdisciplinary team whose members included a geriatrician, an advanced practice nurse, a registered nurse care manager, a social worker, and a geriatric pharmacist. Other clinicians were called on as needed. Primary care physicians, who then received a one-time fee, participated in a consultation with the nurse care manager. Over the course of three years, the Frail Elders Care Management Program served 1,272 patients. Based on promising preliminary results, AHRQ funded a three-year randomized controlled trial.
Key Words: frail elders, care transitions, quality improvement, interdisciplinary teams