After Discharge Management of Low Income Frail Elderly
1 other identifier
interventional
530
0 countries
N/A
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 elderly.
Trial Health
Trial Health Score
Automated assessment based on enrollment pace, timeline, and geographic reach
participants targeted
Target at P75+ for not_applicable
Started Oct 2005
Longer than P75 for not_applicable
Health score is calculated from publicly available data and should be used for screening purposes only.
Trial Relationships
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Study Timeline
Key milestones and dates
Study Start
First participant enrolled
October 1, 2005
CompletedFirst Submitted
Initial submission to the registry
May 18, 2006
CompletedFirst Posted
Study publicly available on registry
May 22, 2006
CompletedPrimary Completion
Last participant's last visit for primary outcome
April 1, 2013
CompletedStudy Completion
Last participant's last visit for all outcomes
April 1, 2013
CompletedJuly 17, 2014
July 1, 2014
7.5 years
May 18, 2006
July 16, 2014
Conditions
Keywords
Outcome Measures
Primary Outcomes (3)
Function
Length of Study
Quality of life
Duration
Quality of medical management
Duration
Secondary Outcomes (2)
Mortality
Duration
Opportunity costs of caregiver time
Duration
Study Arms (1)
Intervention care management
EXPERIMENTALpost dischsrge care management by a nurse care manager who performs in-home vistis and reports to a interdisciplinary team. Team generates care recommendations based on patient goals. PCP and care manager implement the care plan that is based on patient goals. Includes education, behavioral interventions, and coaching.
Interventions
Group Treatment(patient education, self management support, caregiver support)
Eligibility Criteria
You may qualify if:
- \> 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
You may not qualify if:
- 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
Contact the study team to confirm eligibility.
Sponsors & Collaborators
Related Publications (1)
Allen KR, Hazelett SE, Jarjoura D, Wright K, Fosnight SM, Kropp DJ, Hua K, Pfister EW. The after discharge care management of low income frail elderly (AD-LIFE) randomized trial: theoretical framework and study design. Popul Health Manag. 2011 Jun;14(3):137-42. doi: 10.1089/pop.2010.0016. Epub 2011 Feb 15.
PMID: 21323461BACKGROUND
MeSH Terms
Conditions
Condition Hierarchy (Ancestors)
Study Officials
- PRINCIPAL INVESTIGATOR
Kyle R Allen, DO
Riverside Health System
Study Design
- Study Type
- interventional
- Phase
- not applicable
- Allocation
- RANDOMIZED
- Masking
- SINGLE
- Who Masked
- OUTCOMES ASSESSOR
- Purpose
- HEALTH SERVICES RESEARCH
- Intervention Model
- SINGLE GROUP
- Sponsor Type
- OTHER
- Responsible Party
- PRINCIPAL INVESTIGATOR
- PI Title
- Investigator
Study Record Dates
First Submitted
May 18, 2006
First Posted
May 22, 2006
Study Start
October 1, 2005
Primary Completion
April 1, 2013
Study Completion
April 1, 2013
Last Updated
July 17, 2014
Record last verified: 2014-07