Older adults with these chronic diseases often experience poor quality of care and frequent hospital utilization, and account for high health care costs. Care management interventions have shown promise to increase the quality and reduce costs for chronically ill older adults, but few studies have reported on the long-term outcomes of these programs. This randomized controlled trial reports on all-cause mortality outcomes of a community-based nurse care management model, a program designed by Health Quality Partners that includes tailored care plans for patients focused on education, symptom monitoring, medication adherence, referrals to social services, and group weight loss and exercise classes.
There was a 25 percent lower relative risk of death in the intervention group compared to the control group, indicating that this model of care can reduce the all-cause mortality rate for older adults with chronic illnesses. These results also suggest that nurses playing a high-touch role in caring for this population, in collaboration with primary care providers, may improve patients’ long-term health outcomes. While this study was initially conducted as part of the Medicare Coordinated Care Demonstration, this model has since been adapted by Health Quality Partners into the Advanced Preventive Care intervention for chronically ill older adults.