Effect of a Longitudinal, Multifactorial Community-based Nursing Intervention on Mortality in Chronically Ill Older Adults
试验速览
- 阶段
- 不适用
- 发起方
- 入组人数
- 2,000
- 试验地点
- 2
- 主要终点
- All-cause mortality
研究概览
简要总结
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.
详细描述
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).
研究设计
- 研究类型
- Interventional
- 分配方式
- Randomized
- 干预模型
- Parallel
- 主要目的
- Prevention
- 盲法
- None
入排标准
- 年龄范围
- 65 Years 至 —（Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •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
- •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
排除标准
- •Amyotrophic lateral sclerosis
- •Alzheimer's disease
- •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
结局指标
主要结局
All-cause mortality
时间窗: within 5 years of enrollment
次要结局
- 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)