CompletedNot Applicable

After Discharge Management of Low Income Frail Elderly

530 participantsStarted 2005-10

Plain-language 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 elderly.

Who can participate

Age range66 Years

SexALL

See this in plain English?

AI-rewrites the medical criteria so a patient or caregiver can understand them. Always confirm with the trial site.

Inclusion Criteria: * \> 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 Criteria: * 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

What they're measuring

Function

Timeframe: Length of Study

Quality of life

Timeframe: Duration

Quality of medical management

Timeframe: Duration

Trial details

NCT IDNCT00328848

SponsorSumma Health System

Sponsor typeOTHER

Study typeINTERVENTIONAL

Primary completion2013-04

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