Evaluation of a primary care nurse case management intervention for chronically ill community dwelling older people.

Aim: The purpose of this study was to test the effectiveness of a collaborative primary care nurse case management intervention emphasising collaboration between physicians, nurses and patients, risk identification, comprehensive assessment, collaborative planning, health monitoring, patient education and transitional care on healthcare utilisation and cost for community dwelling chronically ill older persons.

Background: Primary care teams comprised of nurses and primary care physicians have been suggested as a model for providing quality care to the chronically ill, but this type of intervention has not been systematically evaluated.

Design: A non-randomised, 36 month comparison of two geographically distinct primary care populations was conducted.

Managing elders with comorbidities.

Carle's Medicare Coordinated Care Demonstration care/disease management interventional components, based on the chronic care model, are described for elderly patients in 13 counties in Illinois. Patients enrolled in the program are diagnosed with chronic obstructive pulmonary disease, coronary artery disease, diabetes, atrial fibrillation, or congestive heart failure. Primary care teams are made up of a primary care physician, an advanced practice nurse, a nurse case manager, and a case assistant.