Effect of a Community-based Nursing Intervention on Mortality in Chronically Ill Older Adults
2013年9月6日 更新者：Health Quality Partners
Effect of a Longitudinal, Multifactorial Community-based Nursing Intervention on Mortality in Chronically Ill Older Adults
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.
研究概览
详细说明
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).
研究类型
介入性
注册 (预期的)
2000
阶段
- 不适用
联系人和位置
本节提供了进行研究的人员的详细联系信息，以及有关进行该研究的地点的信息。
学习地点
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Pennsylvania
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Doylestown、Pennsylvania、美国、18902
- Health Quality Partners
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参与标准
研究人员寻找符合特定描述的人，称为资格标准。这些标准的一些例子是一个人的一般健康状况或先前的治疗。
资格标准
适合学习的年龄
65年 及以上 (年长者)
接受健康志愿者
不
有资格学习的性别
全部
描述
Inclusion Criteria:
- Aged 65 years and older
- Medicare Part A and B traditional, fee for service insurance coverage
- One or more of the following chronic conditions:
- Heart failure
- Coronary Disease
- Diabetes mellitus
- Asthma
- Hypertension
- Hypercholesterolemia
- A Geriatric Risk Stratification Level of 2 or more based on a pre-enrollment screening tool
- Geriatric Risk Stratification Level changed in Sep 2006 to a Level of 3 or more
- Willingness of the participant's primary care provider to collaborate
Exclusion Criteria:
- Amyotrophic lateral sclerosis
- Alzheimer's disease
- Dementia
- Diagnosis or history of cancer (other than skin) in the past 5 years
- End-stage renal disease
- Life expectancy on enrollment less than 6 months
- HIV or AIDS
- Huntington's disease
- Organ transplant candidate
- Psychosis or schizophrenia
- Resident of or imminent plan for long-term nursing home placement
- Seasonal relocation outside of the area for more than 4 weeks per year
- Anyone receiving service from Health Quality Partners in the past
学习计划
本节提供研究计划的详细信息，包括研究的设计方式和研究的衡量标准。
研究是如何设计的？
设计细节
- 主要用途：预防
- 分配：随机化
- 介入模型：并行分配
- 屏蔽：无（打开标签）
武器和干预
参与者组/臂 |
干预/治疗 |
|---|---|
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实验性的：Community-based nurse care management
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.
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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.
其他名称：
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无干预：Usual care
Participants randomized to the control group received usual care without the involvement of a nurse care manager.
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研究衡量的是什么？
主要结果指标
结果测量 |
大体时间 |
|---|---|
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All-cause mortality
大体时间：within 5 years of enrollment
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within 5 years of enrollment
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次要结果测量
结果测量 |
大体时间 |
|---|---|
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Blood pressure control
大体时间：within 5 years of enrollment
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within 5 years of enrollment
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Total cholesterol control
大体时间：within 5 years of enrollment
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within 5 years of enrollment
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Low density cholesterol control
大体时间：within 5 years of enrollment
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within 5 years of enrollment
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Triglycerides control
大体时间：within 5 years of enrollment
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within 5 years of enrollment
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Weight control
大体时间：within 5 years of enrollment
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within 5 years of enrollment
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合作者和调查者
在这里您可以找到参与这项研究的人员和组织。
调查人员
- 首席研究员：Kenneth D Coburn, MD, MPH、Health Quality Partners
出版物和有用的链接
负责输入研究信息的人员自愿提供这些出版物。这些可能与研究有关。
一般刊物
- Peikes D, Chen A, Schore J, Brown R. Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials. JAMA. 2009 Feb 11;301(6):603-18. doi: 10.1001/jama.2009.126.
- Brown R, Peikes D, Chen A, Schore J. 15-site randomized trial of coordinated care in Medicare FFS. Health Care Financ Rev. 2008 Fall;30(1):5-25.
- Bott DM, Kapp MC, Johnson LB, Magno LM. Disease management for chronically ill beneficiaries in traditional Medicare. Health Aff (Millwood). 2009 Jan-Feb;28(1):86-98. doi: 10.1377/hlthaff.28.1.86.
- Coburn KD, Marcantonio S, Lazansky R, Keller M, Davis N. Effect of a community-based nursing intervention on mortality in chronically ill older adults: a randomized controlled trial. PLoS Med. 2012;9(7):e1001265. doi: 10.1371/journal.pmed.1001265. Epub 2012 Jul 17.
研究记录日期
这些日期跟踪向 ClinicalTrials.gov 提交研究记录和摘要结果的进度。研究记录和报告的结果由国家医学图书馆 (NLM) 审查，以确保它们在发布到公共网站之前符合特定的质量控制标准。
研究主要日期
学习开始
2002年4月1日
初级完成 (预期的)
2014年12月1日
研究完成 (预期的)
2016年12月1日
研究注册日期
首次提交
2009年12月16日
首先提交符合 QC 标准的
2010年2月18日
首次发布 (估计)
2010年2月19日
研究记录更新
最后更新发布 (估计)
2013年9月10日
上次提交的符合 QC 标准的更新
2013年9月6日
最后验证
2013年9月1日
更多信息
此信息直接从 clinicaltrials.gov 网站检索，没有任何更改。如果您有任何更改、删除或更新研究详细信息的请求，请联系 register@clinicaltrials.gov. clinicaltrials.gov 上实施更改，我们的网站上也会自动更新.