Status:
COMPLETED
After Discharge Management of Low Income Frail Elderly
Lead Sponsor:
Summa Health System
Conditions:
Heart Failure, Congestive
Coronary Arteriosclerosis
Eligibility:
All Genders
66+ years
Phase:
NA
Brief Summary
The purpose of this study is to determine whether comprehensive post-hospitalization interdisciplinary care management can be an effective care delivery model to improve outcomes in low-income frail e...
Detailed Description
This randomized trial will test the effectiveness of improved clinical practice through comprehensive care management in elderly patients with chronic illness and functional impairment discharged from...
Eligibility Criteria
Inclusion
- \> 65 years old
- Confirmed or probable dual eligible
- Have at least one chronic illness (chronic obstructive pulmonary disease \[COPD\], diabetes, stroke/atrial fibrillation, ischemic heart disease, hypertension, congestive heart failure \[CHF\], osteoporosis, osteoarthritis) and at least 1 impaired activity of daily living (ADL) 11 or 2 impaired instrumental activities of daily living (IADLs)
- Be discharged home or to a skilled nursing facility (or acute rehabilitation) for a maximum of 8 weeks before being discharged to home
Exclusion
- Enrolled in this health system's care management program
- Chemically dependent
- Those with a Mental Status Questionnaire score \> 5
- Diagnosed psychosis
- Dialysis
- Terminal diagnosis/hospice
Key Trial Info
Start Date :
October 1 2005
Trial Type :
INTERVENTIONAL
Allocation :
ACTUAL
End Date :
April 1 2013
Estimated Enrollment :
530 Patients enrolled
Trial Details
Trial ID
NCT00328848
Start Date
October 1 2005
End Date
April 1 2013
Last Update
July 17 2014
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