Effect of a Community-based Nursing Intervention on Mortality in Chronically Ill Older Adults

Study Overview
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Brief Summary
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Care coordination, disease management, geriatric care management, and preventive programs for chronically ill older adults vary in design and their impact on long-term health outcomes is not well established. This study investigates whether a community-based nursing intervention improves longevity and impact on cardiovascular risk factors in this population. The results reflect the impact of one of the study sites (Health Quality Partners) selected by the Centers for Medicare and Medicaid Services (CMS) to participate in the Medicare Coordinated Care Demonstration, a national demonstration designed to identify promising models of care coordination for chronically ill older adults. The study began in April 2002.

Detailed Description
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The community-based nursing care management model developed by Health Quality Partners represents a comprehensive set of integrated preventive and monitoring services designed for older adults living with chronic diseases. The individual programs and services integrated within the model were selected on the basis of previously demonstrated evidence of effectiveness. The model is delivered in the communities in which participants reside. Care is delivered through in person contacts, (1 to 1 and group) as well as by telephone. In person contacts occur in the home, in readily accessible community and faith-based organizations, health facilities, or the offices of Health Quality Partners. Efforts are made to contact participants in the intervention group at least monthly with care continued until death, voluntary disenrollment, mandatory disenrollment due to changes in insurance coverage, relocation out of the service area, or change in long term level of care (e.g., nursing home placement, hospice).

Official Title
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Effect of a Longitudinal, Multifactorial Community-based Nursing Intervention on Mortality in Chronically Ill Older Adults

Conditions
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Heart Failure, Coronary Disease, Diabetes Mellitus, Asthma, Hypertension, Hypercholesterolemia

Intervention / Treatment
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* Other: Community-based nurse care management


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Aged 65 years and older Medicare Part A and B traditional, fee for service insurance coverage One or more of the following chronic conditions: Heart failure Coronary Disease Diabetes mellitus Asthma Hypertension Hypercholesterolemia A Geriatric Risk Stratification Level of 2 or more based on a pre-enrollment screening tool Geriatric Risk Stratification Level changed in Sep 2006 to a Level of 3 or more Willingness of the participant's primary care provider to collaborate Exclusion Criteria: Amyotrophic lateral sclerosis Alzheimer's disease Dementia Diagnosis or history of cancer (other than skin) in the past 5 years End-stage renal disease Life expectancy on enrollment less than 6 months HIV or AIDS Huntington's disease Organ transplant candidate Psychosis or schizophrenia Resident of or imminent plan for long-term nursing home placement Seasonal relocation outside of the area for more than 4 weeks per year Anyone receiving service from Health Quality Partners in the past

Ages Eligible for Study
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Minimum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Community-based nurse care management<br>Participants randomized to receive the intervention worked with a nurse care manager who provided them with a comprehensive set of geriatric and chronic disease preventive services. | Other: Community-based nurse care management<br>* The community-based nurse care management program developed by Health Quality Partners uses nurses working in the community to provide the following integrated set of services to older adults with chronic illness over the long term in order to prevent avoidable complications of their diseases and aging; geriatric assessment, care coordination, health education, self-management coaching, weight management, physical activity, gait and balance training, medication adherence, care transition support, ongoing monitoring and symptom detection, collaborative problem solving with patients, families and health care providers.<br>* Other names: Disease Management;|
| No Intervention: Usual care<br>Participants randomized to the control group received usual care without the involvement of a nurse care manager. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| All-cause mortality |  | within 5 years of enrollment | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Blood pressure control |  | within 5 years of enrollment | 
| Total cholesterol control |  | within 5 years of enrollment | 
| Low density cholesterol control |  | within 5 years of enrollment | 
| Triglycerides control |  | within 5 years of enrollment | 
| Weight control |  | within 5 years of enrollment | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Community Health Nursing, Nursing Care Management, Aged, Aged, 80 and over, Health Services for the Aged, Geriatric Nursing, Geriatric Assessment, Longevity, Mortality