Geriatric Care Management for Low-Income Seniors

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.