Geriatric Care Management for Low-Income Seniors

Counsell, Steve; Callahan, Christopher M.; Clark, Daniel O.; Tu, Wanzhu; Buttar, Amna; Stump, Timothy E.; Ricketts, Gretchen D.

doi:10.1001/jama.298.22.2623

Cited by 448 publications

(573 citation statements)

References 56 publications

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“…In the meantime, however, as millions of baby-boomers are reaching retirement age each year, near-term improvements may be achievable by developing and adopting clinical models that improve outcomes for high-risk people with multiple chronic conditions. Some such models have shown promise, [7][8][9][10][11][12] while others have either failed 13 or have not yet been tested rigorously. 14 Guided Care is a new model of comprehensive, interdisciplinary care that comprises primary care-based care management, transitional care, and support for self-management and family caregiving.…”

Section: Introductionmentioning

confidence: 99%

A Matched-Pair Cluster-Randomized Trial of Guided Care for High-Risk Older Patients

et al. 2013

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BACKGROUND: Patients at risk for generating high health care expenditures often receive fragmented, lowquality, inefficient health care. Guided Care is designed to provide proactive, coordinated, comprehensive care for such patients. OBJECTIVE: We hypothesized that Guided Care, compared to usual care, produces better functional health and quality of care, while reducing the use of expensive health services. DESIGN: 32-month, single-blind, matched-pair, cluster-randomized controlled trial of Guided Care, conducted in eight community-based primary care practices. PATIENTS: The "Hierarchical Condition Category" (HCC) predictive model was used to identify high-risk older patients who were insured by fee-for-service Medicare, a Medicare Advantage plan or Tricare. Patients with HCC scores in the highest quartile (at risk for generating high health care expenditures during the coming year) were eligible to participate. INTERVENTION: A registered nurse collaborated with two to five primary care physicians in providing eight services to participants: comprehensive assessment, evidence-based care planning, proactive monitoring, care coordination, transitional care, coaching for selfmanagement, caregiver support, and access to community-based services. MAIN MEASURES: Functional health was measured using the Short Form-36. Quality of care and health services utilization were measured using the Patient Assessment of Chronic Illness Care and health insurance claims, respectively. KEY RESULTS: Of the eligible patients, 904 (37.8 %) gave written consent to participate; of these, 477 (52.8 %) completed the final interview, and 848 (93.8 %) provided complete claims data. In intention-to-treat analyses, Guided Care did not significantly improve participants' functional health, but it was associated with significantly higher participant ratings of the quality of care (difference=0.27, 95 % CI=0.08-0.45) and 29 % lower use of home care (95 % CI=3-48 %). CONCLUSIONS: Guided Care improves high-risk older patients' ratings of the quality of their care, and it reduces their use of home care, but it does not appear to improve their functional health.

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Section: Introductionmentioning

confidence: 99%

A Matched-Pair Cluster-Randomized Trial of Guided Care for High-Risk Older Patients

et al. 2013

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“…Given the concentration of health expenditures in a subset of complex patients, 5 improving the efficiency of care delivery to this group may help contain costs. [6][7][8][9][10][11][12] Identifying complex, high-risk primary care patients is an important first step that allows healthcare systems to better allocate resources and target interventions. Current quantitative methods for identifying the complex patients at highest risk for suboptimal future clinical quality and utilization outcomes rely primarily on diagnosis-based and utilization-based algorithms to predict future utilization.…”

Section: Introductionmentioning

confidence: 99%

Evaluating a Model to Predict Primary Care Physician-Defined Complexity in a Large Academic Primary Care Practice-Based Research Network

et al. 2015

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BACKGROUND: Improving the ability to risk-stratify patients is critical for efficiently allocating resources within healthcare systems. OBJECTIVE: The purpose of this study was to evaluate a physician-defined complexity prediction model against outpatient Charlson score (OCS) and a commercial risk predictor (CRP). DESIGN: Using a cohort in which primary care physicians reviewed 4302 of their adult patients, we developed a predictive model for estimated physician-defined complexity (ePDC) and categorized our population using ePDC, OCS and CRP. PARTICIPANTS: 143,372 primary care patients in a practice-based research network participated in the study. MAIN MEASURES: For all patients categorized as complex in 2007 by one or more risk-stratification method, we calculated the percentage of total person time from 2008-2011 for which eligible cancer screening was incomplete, HbA1c was ≥ 9 %, and LDL was ≥ 130 mg/dl (in patients with cardiovascular disease). We also calculated the number of emergency department (ED) visits and hospital admissions per person year (ppy). KEY RESULTS: There was modest agreement among individuals classified as complex using ePDC compared with OCS (36.7 %) and CRP (39.6 %). Over 4 follow-up years, eligible ePDC-complex patients had higher proportions (p<0.001) of time with: incomplete cervical (17.8 % vs. 13.3 % for OCS; 19.4 % vs. 11.2 % for CRP), breast (21.4 % vs. 14.9 % for OCS; 22.7 % vs. 15.0 % for CRP), and colon (25.9 % vs. 18.7 % for OCS; 27.0 % vs. 18.2 % for CRP) cancer screening; HbA1c≥9 % (15.6 % vs. 8.1 % for OCS; 15.9 % vs. 6.9 % for CRP); and LDL≥130 mg/dl (12.4 % vs. 7.9 % for OCS; 11.8 % vs 9.0 % for CRP). ePDCcomplex patients had higher rates (p<0.003) of: ED visits (0.21 vs. 0.11 ppy for OCS; 0.17 vs. 0.15 ppy for CRP), and admissions in patients 45-64 and ≥ 65 years old (0.11 vs. 0.10 ppy AND 0.24 vs. 0.21 ppy for OCS). CONCLUSION: Our measure for estimated physiciandefined complexity compared favorably to commonly used risk-prediction approaches in identifying future suboptimal quality and utilization outcomes.

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“…The Expanded Team consists of a variety of specialty resources. Similar teams have been associated with improvements in efficiency, mortality, hospitalization, access, and coordination [2][3][4][5][6][7][8]. Figure 1 illustrates the relationship infrastructure of PACT team members.…”

mentioning

confidence: 99%

The role of mental and behavioral health in the application of the patient-centered medical home in the Department of Veterans Affairs

Kearney¹,

Post²,

Zeiss

et al. 2011

Behav. Med. Pract. Policy Res.

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Geriatric Care Management for Low-Income Seniors

Cited by 448 publications

References 56 publications

A Matched-Pair Cluster-Randomized Trial of Guided Care for High-Risk Older Patients

A Matched-Pair Cluster-Randomized Trial of Guided Care for High-Risk Older Patients

Evaluating a Model to Predict Primary Care Physician-Defined Complexity in a Large Academic Primary Care Practice-Based Research Network

The role of mental and behavioral health in the application of the patient-centered medical home in the Department of Veterans Affairs

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