An interventional study of Community-based nurse care management in Heart Failure, Coronary Disease and Diabetes Mellitus, sponsored by Health Quality Partners. Status unknown at 1 site in United States. Open to participants aged 65 Years and older. Per ClinicalTrials.gov, last updated 2013-09-10.
Sponsored by Health Quality Partners · Not applicable, Interventional, and Prevention
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.
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).
2,839 studies on the registry are indexed under Coronary Disease; 311 are open to participants now.
This study's planned enrollment of 2,000 is above the median of 124 across 1,583 interventional studies indexed under Coronary Disease.
Browse Coronary Disease studies →This is the only study on the registry with Health Quality Partners as lead sponsor.
Counted across the registry records on this site, refreshed daily.
Exclusion Criteria:
Participants randomized to receive the intervention worked with a nurse care manager who provided them with a comprehensive set of geriatric and chronic disease preventive services.
Other: Community-based nurse care management
Participants randomized to the control group received usual care without the involvement of a nurse care manager.
The community-based nurse care management program developed by Health Quality Partners uses nurses working in the community to provide the following integrated set of services to older adults with chronic illness over the long term in order to prevent avoidable complications of their diseases and aging; geriatric assessment, care coordination, health education, self-management coaching, weight management, physical activity, gait and balance training, medication adherence, care transition support, ongoing monitoring and symptom detection, collaborative problem solving with patients, families and health care providers.
Also known as: Health Quality Partners, Medicare Coordinated Care Demonstration, Care Coordination, Disease Management
All-cause mortality
Time frame: within 5 years of enrollment
Blood pressure control
Time frame: within 5 years of enrollment
Total cholesterol control
Time frame: within 5 years of enrollment
Low density cholesterol control
Time frame: within 5 years of enrollment
Triglycerides control
Time frame: within 5 years of enrollment
Weight control
Time frame: within 5 years of enrollment
This study is status unknown, as verified in Sep 2013. You cannot join it, but the record below documents what was studied.
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