Multidisciplinary team key to chronic care

Proof that DM/chronic care management can be effective in the older, sicker population of Medicare patients might be found in small programs rather than in large programs such as Medicare Health Support.

Take, for example, a three-year demonstration called After Discharge Care Management of Low Income Frail Elderly (AD-LIFE), a program funded by the Agency for Health Research and Quality (AHRQ) that’s now entering its third year in Akron, OH. The goal of the initiative is to reduce hospital readmissions and nursing home placements, as well as overall functional decline and decreased quality of life.

“We haven’t been allowed to look at the actual data as yet, but all of the anecdotal findings point to the fact that the team approach is improving the quality of health for the patients enrolled,” says Kyle Allen, DO, a geriatrician and medical director at Summa Health System in Akron and principal investigator of the AD-LIFE study.

A smaller pilot study done at Summa Health before the AD-LIFE trial included 118 patients. It showed that the intervention of a multidisciplinary care team that focused on individual management of patients with more than one chronic disease resulted in decreased hospital admissions and decreased costs.1 The pilot compared the cost of prehospitalization with a one-year post-care management implementation. The results showed a savings of approximately $1,000 per patient per month, says Allen.

So far, the AD-LIFE trial has enrolled 300 patients with a goal of 533 by the end of this year. In many ways, the design of this trial would seem to defy all previous theories about what population is most likely to improve with individualized care management. Patients in this trial are all low-income and are Medicaid eligible and nursing home certifiable. They must have more than one comorbid condition, have posthospital discharge complications, and be limited in at least one activity of daily living (e.g., feeding, bathing, or dressing) or two instrumental activities of daily living (e.g., preparing meals, taking medications, or grocery shopping).

Patients must be able to return home after discharge or after a short stay in long-term care. In addition to these inclusion criteria, patients are tested for cognitive impairment. Allen says although mild dementia doesn’t prohibit patients from being able to benefit from the study intervention, moderate and severe dementia would be an excluding factor in enrollment.

“The diversity of people enrolled in the program so far is amazing,” says Kathy Wright, MSN, RN, APN, BC, coinvestigator of the trial. “There are so many examples of patients referred to the study who were homebound or who had one foot into a nursing home and now are living independently,” she says.

Many of the patients had psychosocial issues, such as caregiver support and geriatric syndromes, including incontinence, depression, and dementia. Wright and Allen say these issues, and other intangibles that make it harder for these patients to be more self-directed, are often present in older Medicare patients. But, they say, these issues are often not accounted for in DM programs that focus more on the disease than the individual person.

“These patients need a navigator, either a registered nurse or a social worker, tied to a multidisciplinary team that manages patients with higher disease risk and higher utilization of services,” says Allen.

And that’s what the AD-LIFE trials provide—each enrollee is followed by a case manager who is part of a multidisciplinary care team that includes a geriatrician, an RN, a pharmacist, and a social worker. Other specialists, such as occupational, physical, and speech therapists, might be added to the team if necessary.

Allen says medication management is a key to the management of these patients, adding that many chronically ill patients who are on a host of medications end up having a medication-related adverse event that puts them back in the hospital within a few weeks after discharge. A key member of the team is the geriatric pharmacist who does a review of all of the patient’s medications.

Intervention elements

AD-LIFE trial patients are referred to Summa Health by the local Area Agency on Aging (AAoA) for frail elderly. Wright says the trial uses the social services of the AAoA (e.g., home health aides, transportation, mobile meals, portable weight scales), but adds on the elements of a comprehensive geriatric assessment, the care management team, an individualized evidenced-based care plan, and a focus on patient self-care and education about their chronic illness. The patients are followed for one year after hospital discharge.

The implementation of the care management begins while the patient is still in the hospital to improve the transition between inpatient and outpatient care, Wright says. The care manager does the in-home assessment within one week of discharge and develops and implements a care plan that is shared with the patient’s PCP. Other tasks that the care manager performs include:

  • Ensuring access to medical and social services
  • Educating the patient about signs and symptoms of chronic illness exacerbation and appropriate response if symptoms occur
  • Informing and motivating the patient about lifestyle changes, such as smoking, exercise, alcohol consumption, and diet
  • Ensuring medication appropriateness
  • Ensuring continuity of care by communicating with all medical and social service personnel who interact with the particular patient

Case managers meet with the PCP to discuss the one-page care plan, which serves as an icebreaker between the nurse and doctor. “This is different than traditional disease management, in which doctors are bombarded with case managers who they feel are interfering with their management of the patient,” Wright says.

Allen says Summa Health System doctors benefit from the case manager, and physicians see the “AD-LIFE participation as a downstream benefit and true resource.”

Self-motivation is important in this patient population. “Since these patients are low-income, there is a certain social reluctance to take on a more direct role in their own care,” says Allen. “In many cases, they have never been asked to challenge low expectations about their own healthcare.”

Wright says case managers let the patients set their own goals. They help the patient develop and keep personal medical records, including a living will and advance directives for healthcare.

“Educated patients bring all of their medical information and a list of medications to each doctor’s visit and keep medications organized to prevent errors,” Wright says.

“They learn to know their own body, be alert to changes, and know how to distinguish between non-urgent and urgent needs … They also know that if they don’t understand medical terminology, they should not hesitate to ask questions,” she adds.

Allen says the trial has helped patients who came into it just trying to survive and has improved health disparities and health literacy.

The program allows for more one-on-one time with the patients, Wright says, citing an example of a woman who had to use a motorized scooter when she enrolled in the trial.

The woman was close to needing nursing home care because of her immobility. She started taking water therapy classes, lost 25 lb., and no longer needed the scooter.

Trial patients now initiate calls to the doctor’s office to report a symptom or ask for test results, says Wright. “They don’t have a wait-and-see attitude anymore,” she adds.

Allen says the trial is funded by AHRQ through October, but he hopes to get additional funding to perform another full year. The additional 12 months of data will help verify that these interventions are working, he adds.


1. Wright, K, Hazelett, S, Jarjoura D, and Allen K. “The AD-LIFE Trial: Working to Integrate Medical and Psychosocial Care Management Models.” Home Healthcare Nurse 2007; 25(5):308–314.




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