This Article  • Full text  • PDF  • The JAMA Report  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on ISI (3)  • Contact me when this article is cited  Related Content  • Related article  • Similar articles in JAMA  Topic Collections  • Aging/ Geriatrics  • Medical Practice, Other  • Randomized Controlled Trial  • Alert me on articles by topic

A Randomized Controlled Trial

Steven R. Counsell, MD; Christopher M. Callahan, MD; Daniel O. Clark, PhD; Wanzhu Tu, PhD; Amna B. Buttar, MD, MS; Timothy E. Stump, MS; Gretchen D. Ricketts, BSW

JAMA. 2007;298(22):2623-2633.

Context  Low-income seniors frequently have multiple chronic medical conditions for which they often fail to receive the recommended standard of care.

Objectives  To test the effectiveness of a geriatric care management model on improving the quality of care for low-income seniors in primary care.

Design, Setting, and Patients  Controlled clinical trial of 951 adults 65 years or older with an annual income less than 200% of the federal poverty level, whose primary care physicians were randomized from January 2002 through August 2004 to participate in the intervention (474 patients) or usual care (477 patients) in community-based health centers.

Intervention  Patients received 2 years of home-based care management by a nurse practitioner and social worker who collaborated with the primary care physician and a geriatrics interdisciplinary team and were guided by 12 care protocols for common geriatric conditions.

Main Outcome Measures  The Medical Outcomes 36-Item Short-Form (SF-36) scales and summary measures; instrumental and basic activities of daily living (ADLs); and emergency department (ED) visits not resulting in hospitalization and hospitalizations.

Results  Intention-to-treat analysis revealed significant improvements for intervention patients compared with usual care at 24 months in 4 of 8 SF-36 scales: general health (0.2 vs –2.3, P = .045), vitality (2.6 vs –2.6, P < .001), social functioning (3.0 vs –2.3, P = .008), and mental health (3.6 vs –0.3, P = .001); and in the Mental Component Summary (2.1 vs –0.3, P < .001). No group differences were found for ADLs or death. The cumulative 2-year ED visit rate per 1000 was lower in the intervention group (1445 [n = 474] vs 1748 [n = 477], P = .03) but hospital admission rates per 1000 were not significantly different between groups (700 [n = 474] vs 740 [n = 477], P = .66). In a predefined group at high risk of hospitalization (comprising 112 intervention and 114 usual-care patients), ED visit and hospital admission rates were lower for intervention patients in the second year (848 [n = 106] vs 1314 [n = 105]; P = .03 and 396 [n = 106] vs 705 [n = 105]; P = .03, respectively).

Conclusions  Integrated and home-based geriatric care management resulted in improved quality of care and reduced acute care utilization among a high-risk group. Improvements in health-related quality of life were mixed and physical function outcomes did not differ between groups. Future studies are needed to determine whether more specific targeting will improve the program's effectiveness and whether reductions in acute care utilization will offset program costs.

Trial Registration  clinicaltrials.gov Identifier: NCT00182962

Author Affiliations: Indiana University Center for Aging Research (Drs Counsell, Callahan, Clark, and Tu, Mr Stump, and Ms Ricketts) and Department of Medicine (Drs Counsell, Callahan, Clark, and Tu), Indiana University School of Medicine, Indianapolis; Regenstrief Institute Inc, Indianapolis, Indiana (Drs Counsell, Callahan, Clark, and Tu, Mr Stump, and Ms Ricketts); and Department of Medicine, University of Wisconsin Medical School, Madison (Dr Buttar).

RELATED ARTICLE

Better Care for Older People With Chronic Diseases: An Emerging Vision
David B. Reuben
JAMA. 2007;298(22):2673-2674.
EXTRACT | FULL TEXT  

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Self reported receipt of care consistent with 32 quality indicators: national population survey of adults aged 50 or more in England
Steel et al.
BMJ 2008;337:a957-a957.
ABSTRACT | FULL TEXT  

How to Improve Coordination of Care
Semla
ANN INTERN MED 2008;148:627-628.
FULL TEXT  

Multidimensional Geriatric Assessment: Back to the Future Multidimensional Preventive Home Visit Programs for Community-Dwelling Older Adults: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
Huss et al.
J. Gerontol. A Biol. Sci. Med. Sci. 2008;63:298-307.
ABSTRACT | FULL TEXT  

Better Care for Older People With Chronic Diseases: An Emerging Vision
Reuben
JAMA 2007;298:2673-2674.
FULL TEXT