A randomized trial of group outpatient visits for chronically ill older HMO members: the Cooperative Health Care Clinic

A broader paradigm for understanding and treating heart failure

Several recent clinical trials in heart failure have failed to demonstrate improvements in survival, suggesting that new approaches must be adopted if there are to be further improvements in heart failure treatment. We propose a broader paradigm for heart failure care based on a chronic rather than an acute illness model. This approach recognizes a broader range of outcomes including patient-perceived health status, expanded populations of interest that more closely reflect the changing epidemiology of heart failure, and a wider scope of interventions that address co-morbidity and health behavior. This approach will require a rationally designed health care delivery system that applies the best available evidence to the care of individual patients with heart failure.

Changing office practice and health care systems to facilitate diabetes self-management

Diabetes is a self-managed disease for which patients provide 99% of their own care. For patients to succeed as diabetes self-managers, they need office practices and health care systems that can prepare and support them in their diabetes self-management efforts over the long term. In order to provide effective diabetes education and ongoing support, office practices and health care systems will have to fundamentally redefine the roles of health professionals and patients with diabetes, and redesign practices and systems to allow for effective long-term self-management education and support. Although it is difficult for both people and systems to change, change is essential if we are going to provide self-management support for the majority of patients suffering from this serious chronic disease.

The impact of a health education program targeting patients with high visit rates in a managed care organization

PURPOSE

To determine if a mailed health promotion program reduced outpatient visits while improving health status.

DESIGN

Randomized controlled trial.

SETTING

A midsized, group practice model, managed care organization in Ohio.

SUBJECTS

Members invited (N = 3214) were high utilizers, 18 to 64 years old, with hypertension, diabetes, or arthritis (or all). A total of 886 members agreed to participate, and 593 members returned the initial questionnaires. The 593 members were randomized to the following groups: 99 into arthritis treatment and 100 into arthritis control, 94 into blood pressure treatment and 92 into blood pressure control, and 104 into diabetes treatment and 104 into diabetes control.

MEASURES

Outpatient utilization, health status, and self-efficacy were followed over 30 months.

INTERVENTIONS

Health risk appraisal questionnaires were mailed to treatment and control groups before randomization and at 1 year. The treatment group received three additional condition-specific (arthritis, diabetes, or hypertension) questionnaires and a health information handbook. The treatment group also received written health education materials and an individualized feedback letter after each returned questionnaire. The control group received condition-specific written health education materials and reimbursement for exercise equipment or fitness club membership after returning the 1-year end of the study questionnaire.

RESULTS

Changes in visit rates were disease specific. Parameter estimates were calculated from a Poisson regression model. For intervention vs. controls, the arthritis group decreased visits 4.84 per 30 months (p < 0.00), the diabetes group had no significant change, and the hypertension group increased visits 2.89 per 30 months (p < 0.05), the overall health status improved significantly (-6.5 vs. 2.3, p < 0.01) for the arthritis group but showed no significant change for the other two groups, and coronary artery disease and cancer risk scores did not change significantly for any group individually. Overall self-efficacy for intervention group completers improved by -8.6 points (p < 0.03) for the arthritis group, and the other groups showed no significant change.

CONCLUSIONS

This study demonstrated that in a population of 18 to 64 years with chronic conditions, mailed health promotion programs might only benefit people with certain conditions.

Challenges of systems of care for frail older persons: the United States of America experience

The concomitant demographic and economic imperatives of an increasingly aged and frail population in the United States provide a compelling rationale for the development of systems of care that provide greater integration and improved quality of care. After providing the supporting statistics that illuminate the challenges faced by this country, this article then examines the current organization and financing of services pertinent to the care of frail older adults. These individual services, however, comprise a continuum of care more by default than by design. Greater integration is needed to meet the needs of this population that requires care from different providers in multiple settings. Fortunately, innovations are being implemented that integrate acute care with chronic and long-term care, providing reason for hope that the health care system in the United States is responding to these imperatives.

Assessment of chronic illness care (ACIC): a practical tool to measure quality improvement

OBJECTIVE

To describe initial testing of the Assessment of Chronic Illness Care (ACIC), a practical quality-improvement tool to help organizations evaluate the strengths and weaknesses of their delivery of care for chronic illness in six areas: community linkages, self-management support, decision support, delivery system design, information systems, and organization of care.

DATA SOURCES

(1) Pre-post, self-report ACIC data from organizational teams enrolled in 13-month quality-improvement collaboratives focused on care for chronic illness; (2) independent faculty ratings of team progress at the end of collaborative.

STUDY DESIGN

Teams completed the ACIC at the beginning and end of the collaborative using a consensus format that produced average ratings of their system's approach to delivering care for the targeted chronic condition. Average ACIC subscale scores (ranging from 0 to 11, with 11 representing optimal care) for teams across all four collaboratives were obtained to indicate how teams rated their care for chronic illness before beginning improvement work. Paired t-tests were used to evaluate the sensitivity. of the ACIC to detect system improvements for teams in two (of four) collaboratives focused on care for diabetes and congestive heart failure (CHF). Pearson correlations between the ACIC subscale scores and a faculty rating of team performance were also obtained.

RESULTS

Average baseline scores across all teams enrolled at the beginning of the collaboratives ranged from 4.36 (information systems) to 6.42 (organization of care), indicating basic to good care for chronic illness. All six ACIC subscale scores were responsive to system improvements diabetes and CHF teams made over the course of the collaboratives. The most substantial improvements were seen in decision support, delivery system design, and information systems. CHF teams had particularly high scores in self-management support at the completion of the collaborative. Pearson correlations between the ACIC subscales and the faculty rating ranged from .28 to .52.

CONCLUSION

These results and feedback from teams suggest that the ACIC is responsive to health care quality-improvement efforts and may be a useful tool to guide quality improvement in chronic illness care and to track progress over time.

Performance of the provider satisfaction inventory to measure provider satisfaction with diabetes care

OBJECTIVE

To develop and validate an inventory to measure provider satisfaction with diabetes management.

METHODS

Using the Mayo Clinic Model of Care, a review of the literature, and expert input, we developed a 4-category (chronic disease management, collaborative team practice, outcomes, and supportive environment), 29-item, 7-point-per-item Provider Satisfaction Inventory (PSI). For evaluation of the PSI, we mailed the survey to 192 primary-care and specialized providers from 8 practice sites (of whom 60 primary-care providers were participating in either usual or planned diabetes care). The Cronbach a score was used to assess the instrument's internal reliability. Participating providers indicated satisfaction or dissatisfaction with management of chronic disease by responding to 29 statements.

RESULTS

The response rate was 58%. In each category, the Cronbach a score ranged from 0.71 to 0.90. Providers expressed satisfaction with patient-physician relationships, with the contributions of the nurse educator to the team, and with physician leadership. Providers were dissatisfied with their ability to spend adequate time with the patient (3.6 +/- 1.4), their ability to give patients with diabetes necessary personal attention (4.1 +/- 1.2), the efficient passing of communication (4.3 +/- 1.2), and the opportunities for input to change practice (4.3 +/- 1.6). No statistically significant difference (P = 0.12) was found in mean total scores between planned care (5.0 +/- 0.5) and usual care (4.7 +/- 0.6) providers. Moreover, no significant differences were noted across practice sites.

CONCLUSION

The PSI is a reliable and preliminarily valid instrument for measuring provider satisfaction with diabetes care. Use in research and quality improvement activities awaits further validation.

Organizational interventions to improve health outcomes of older persons

BACKGROUND

With the reorganization of the financing of health care and creation of systems of care, it is possible to design and implement organizational interventions to improve the care of older persons beyond the services that can be provided by an individual provider.

OBJECTIVES

To review the effectiveness of organizational interventions for older persons, describe barriers to dissemination of success models into practice settings, and identify future directions for such interventions.

METHODS

Selective review of organizational interventions that have been aimed primarily at the geriatric population and have been formally evaluated using conventional research designs, usually randomized clinical trials.

RESULTS

Organizational interventions can be classified into two groups: component models and systems changes. The former can be superimposed upon an intact system but do not fundamentally change the system of care whereas the latter modify the basic structure of primary care. A variety of organizational interventions have been implemented in diverse settings, but the evidence supporting the effectiveness of these interventions is inconsistent. Even when such interventions have been effective in research settings, these interventions rarely reduce health care costs. Moreover, there have been formidable barriers to implementation of successful interventions into practice.

CONCLUSIONS

Organizational interventions are potentially powerful methods to influence health care and maintain health status of older persons. Nevertheless, gaps between knowledge and practice and unanswered questions about the effectiveness of organizational interventions currently limit the potential value of this approach to improving health care of older persons.

Self-care and the doctor-patient relationship

OBJECTIVES

An important factor contributing to the steep rise in health care costs in the late 1960s was a reversal from the predominance of acute illness to that of chronic disease. Beginning with the philosophy of Illich and Levin, and the practical instruments of Fries, Sehnert, Vickery, and Ferguson, a new movement in patient self-care emerged. However, such programs were not integrated into organized medical care plans and though theoretically attractive had not yet proven to improve health or decrease costs.

METHODS

The contributions to the self-care movement made under the intellectual guidance of Halsted Holman and the relevant literature produced are reviewed.

RESULTS

While caring for chronic rheumatic diseases, Halsted Holman discovered that patient self-report was a more powerful predictor of outcome than were traditional biologic measures such as anti-DNA antibodies. Realizing the role that patient knowledge of their own disease course might play, he developed the Arthritis Self-Management course, a lay-led self-care program emphasizing patient participation. Holman and colleagues next elucidated the pivotal importance of Bandura's theory of self-efficacy in the improved patient outcomes initially observed. These self-care techniques were woven into the structure of the Midpeninsula Health Service, showing for the first time reductions in subsequent office visits and enhanced quality. In partnership with Kaiser Health Plan, these techniques showed improvements in self-efficacy health behaviors, status, and use in a randomized trial of more than 1,000 patients.

CONCLUSION

Halsted Holman and colleagues have played a seminal role in the translation of academic self-care theory into community practice.

A randomized comparison of home visits and hospital-based group follow-up visits after early postpartum discharge

OBJECTIVE

Short postpartum stays are common. Current guidelines provide scant guidance on how routine follow-up of newly discharged mother-infant pairs should be performed. We aimed to compare 2 short-term (within 72 hours of discharge) follow-up strategies for low-risk mother-infant pairs with postpartum length of stay (LOS) of <48 hours: home visits by a nurse and hospital-based follow-up anchored in group visits.

METHODS

We used a randomized clinical trial design with intention-to-treat analysis in an integrated managed care setting that serves a largely middle class population. Mother-infant pairs that met LOS and risk criteria were randomized to the control arm (hospital-based follow-up) or to the intervention arm (home nurse visit). Clinical utilization and costs were studied using computerized databases and chart review. Breastfeeding continuation, maternal depressive symptoms, and maternal satisfaction were assessed by means of telephone interviews at 2 weeks postpartum.

RESULTS

During a 17-month period in 1998 to 1999, we enrolled and randomized 1014 mother-infant pairs (506 to the control group and 508 to the intervention group). There were no significant differences between the study groups with respect to maternal age, race, education, household income, parity, previous breastfeeding experience, early initiation of prenatal care, or postpartum LOS. There were no differences with respect to neonatal LOS or Apgar scores. In the control group, 264 mother-infant pairs had an individual visit only, 157 had a group visit only, 64 had both a group and an individual visit, 4 had a home health and a hospital-based follow-up, 13 had no follow-up within 72 hours, and 4 were lost to follow-up. With respect to outcomes within 2 weeks after discharge, there were no significant differences in newborn or maternal hospitalizations or urgent care visits, breastfeeding discontinuation, maternal depressive symptoms, or a combined clinical outcome measure indicating whether a mother-infant pair had any of the above outcomes. However, mothers in the home visit group were more likely than those in the control group to rate multiple aspects of their care as excellent or very good. These included the preventive advice delivered (76% vs 59%) and the skills and abilities of the provider (84% vs 73%). Mothers in the home visit group also gave higher ratings on overall satisfaction with the newborn's posthospital care (71% vs 59%), as well as with their own posthospital care (63% vs 55%). The estimated cost of a postpartum home visit to the mother and the newborn was $265. In contrast, the cost of the hospital-based group visit was $22 per mother-infant pair; the cost of an individual 15-minute visit with a registered nurse was $52; the cost of a 15-minute individual pediatrician visit was $92; and the cost of a 10-minute visit with an obstetrician was $92.

CONCLUSIONS

For low-risk mothers and newborns in an integrated managed care organization, home visits compared with hospital-based follow-up and group visits were more costly but achieved comparable clinical outcomes and were associated with higher maternal satisfaction. Neither strategy is associated with significantly greater success at increasing continuation of breastfeeding. This study had limited power to identify group differences in rehospitalization and may not be generalizable to higher-risk populations without comparable access to integrated hospital and outpatient care.

Chronic care clinics for diabetes in primary care: a system-wide randomized trial

OBJECTIVE

To evaluate the impact of primary care group visits (chronic care clinics) on the process and outcome of care for diabetic patients.

RESEARCH DESIGN AND METHODS

We evaluated the intervention in primary care practices randomized to intervention and control groups in a large-staff model health maintenance organization (HMO). Patients included diabetic patients > or = 30 years of age in each participating primary care practice, selected at random from an automated diabetes registry. Primary care practices were randomized within clinics to either a chronic care clinic (intervention) group or a usual care (control) group. The intervention group conducted periodic one-half day chronic care clinics for groups of approximately 8 diabetic patients in their respective doctor's practice. Chronic care clinics consisted of standardized assessments; visits with the primary care physician, nurse, and clinical pharmacist; and a group education/peer support meeting. We collected self-report questionnaires from patients and data from administrative systems. The questionnaires were mailed, and telephoned interviews were conducted for nonrespondents, at baseline and at 12 and 24 months; we queried the process of care received, the satisfaction with care, and the health status of each patient. Serum cholesterol and HbA1c levels and health care use and cost data was collected from HMO administrative systems.

RESULTS

In an intention-to-treat analysis at 24 months, the intervention group had received significantly more recommended preventive procedures and helpful patient education. Of five primary health status indicators examined, two (SF-36 general health and bed disability days) were significantly better in the intervention group. Compared with control patients, intervention patients had slightly more primary care visits, but significantly fewer specialty and emergency room visits. Among intervention participants, we found consistently positive associations between the number of chronic care clinics attended and a number of outcomes, including patient satisfaction and HbA1c levels.

CONCLUSIONS

Periodic primary care sessions organized to meet the complex needs of diabetic patients imrproved the process of diabetes care and were associated with better outcomes.

Health education groups for caregivers in an HMO

The short-term effectiveness of a Health Education Group (HEP) intervention program for spouses of frail older adults was compared to the usual care (UC) offered to the spouses of frail older persons in a staff model health maintenance organization. HEP is a multicomponent group program offered in eight weekly, two-hour group sessions, and ten monthly, two-hour follow-up group sessions. It includes emotion-focused and problem-focused coping strategies, education, and support. One-hundred and five spouses were recruited and randomly assigned to HEP (n = 58) or UC (n = 47). Spouse caregivers and care recipients were assessed within two weeks of intervention and within two weeks after the completion of the eight weekly group meetings. The results indicate that, for caregivers, HEP was more effective than UC in reducing depression, maintaining social integration, increasing effectiveness in solving pressing problems, increasing knowledge of community services and how to access them, changing caregivers' feelings of competence, and the way they respond to the care giving situation. No significant differences, however, were found between care recipients in the two arms of the study on any of the outcome measures.

Effects on quality of care for patients with NIDDM or COPD when the specialised nurse has a central role: a literature review

Chronic care has to be organised in a way that care from any one caregiver is linked up to that provided by others so that disturbing gaps, contradictions and overlaps are avoided. In the search for the most effective and efficient combination of health professionals to deliver care to chronic patients, the role of the specialised nurse has become important. This article reviews a Medline search for publications about the effects of models of care for patients with NIDDM or COPD in which the specialised nurse has a central role. Main features of the models are identified and related to expected and statistically significant effects. In this young domain of effect evaluation ten publications met our criteria. Depending on the division of tasks between care providers, improvements are seen in self-care, quality of life and patient satisfaction, as well as increased medical consumption. More methodologically suitable evaluations with the use of only valid measures are needed.

Elements of Effective Chronic Care: A Model for Optimizing Outcomes for the Chronically Ill

Current estimates are that there are 2.3 million individuals with epilepsy among 99 million Americans suffering from chronic medical conditions. The healthcare system is designed to treat acutely ill patients and, as a result, often fails to meet the needs of the chronically ill. Care is provided in brief, problem-focused visits. Multiple studies have shown that this type of standard practice produces suboptimal care and outcomes, and is unsatisfactory to both patients and care providers. We developed the Chronic Care Model in an effort to synthesize system and practice changes associated with better outcomes. In patient care as described in this model, patient-provider interactions are planned in advance in accordance with evidence-based guidelines. A primary focus is on assisting patients and their families in becoming competent self-managers. The Chronic Care Model has been successfully implemented by more than 200 healthcare systems. In this paper, we explore the applicability of the Chronic Care Model in managing patients with epilepsy.

Making capitated Medicare work for women: policy and research challenges

Growth in capitated Medicare has special ramifications for older women who comprise the majority of Medicare beneficiaries. Older women are more likely than men to have chronic conditions that lead to illness and disability, and they often have fewer financial and social resources to cope with these problems. Gender differences in health status have a number of important implications for the financing and delivery of care for older women under both traditional fee-for-service Medicare and capitation. The utilization of effective preventive interventions, new therapeutic interventions for the management of common chronic disorders, and more cost-effective models of chronic disease management could potentially extend the active life expectancy of older women. However, there are financial and delivery system barriers to achieving these objectives. Traditional FFS Medicare has gaps in coverage of care for chronic illness and disability that disproportionately impact women. Managed care potentially offers flexibility to allocate resources creatively, to develop new models of care, and offer enhanced benefits with lower out-of-pocket costs. However, challenges to realizing this potential under Medicare managed care with unique implications for older women include: possible gender bias in capitation payments, risk selection, inadequacy of risk adjustment models, benefit and market instability, and disenrollment patterns.

Interdisciplinary geriatric primary care evaluation and management: two-year outcomes

BACKGROUND

The long-term efficacy of interdisciplinary outpatient primary care Geriatric Evaluation and Management (GEM) has not been proven. This article focuses on results obtained during the 2 years of the study.

METHODS

In this 2-year randomized clinical trial, at the Veterans Affairs Medical Center, Memphis, TN, 128 veterans, age 65 years and older, were randomized to outpatient GEM or usual care (UC). Two-year follow-up analyses are based on the 98 surviving individuals. Study outcome measurements included health status, function, and quality of life including affect, cognition, and mortality.

RESULTS

At 2 years, there were positive intervention effects for eight of 1 outcome measures, five of which had attained significance at 1 year. GEM subjects, compared with UC subjects, had significantly greater improvement in health perception (P = .001), smaller increases in numbers of clinic visits (P = .019) and instrumental activities of daily living (IADL) impairments (P = .006), improved social activity (P<.001), greater improvement in Center for Epidemiologic Studies-Depression (CES-D) scores (P = .003), general well-being (P = .001), life satisfaction (P<.001), and Mini-Mental State Exam (MMSE) scores (P = .025). There were no significant treatment effects in activities of daily living (ADL) scores (P = .386), number of hospitalizations (P = .377), or mortality (P = .155).

CONCLUSIONS

These findings suggest that a primary care approach that combines an initial interdisciplinary comprehensive assessment with long-term, interdisciplinary outpatient management may improve outcomes for targeted older adults significantly. Findings suggest further that outcomes may continue to improve over time and that the GEM care model provides an effective way to manage health care of older adults.

Effectiveness of professional--peer group treatment: symptom management for women with PMS

The purpose of this intervention study was to determine short- and long-term effectiveness of a symptom management intervention aimed at relieving the distress associated with premenstrual syndrome (PMS). The PMS Symptom Management Program (PMS-SMP), a package of nonpharmacological strategies involving self-monitoring, personal choice, self-regulation, and self/environmental modification, was administered within a group combining peer support and professional guidance to 91 women classified with severe PMS (early treatment groups n = 40; waiting treatment groups n = 51). Repeated behavioral measures (symptom severity and personal resources/demands) were obtained on five occasions: two menstrual cycles prior to treatment and at 3, 6, 12, and 18 months after treatment. A package of symptom management strategies was effective in reducing PMS severity by 75%, premenstrual depression, and general distress by 30-54%, as well as increasing well-being and self-esteem in women experiencing severe PMS. These results compare favorably with antidepressant drug treatment studies that report a 40-52% reduction in PMS severity. The most marked improvement was found in the first 3 months after treatment; however, improvement was maintained or enhanced in the long-term follow-up. Although focused on perimenstrual symptom relief, these strategies are generally health promoting and can be applied to other women's health conditions.

Chronic care clinics: a randomized controlled trial of a new model of primary care for frail older adults

OBJECTIVE

To determine whether a new model of primary care, Chronic Care Clinics, can improve outcomes of common geriatric syndromes (urinary incontinence, falls, depressive symptoms, high risk medications, functional impairment) in frail older adults.

DESIGN

Randomized controlled trial with 24 months of follow-up. Physician practices were randomized either to the Chronic Care Clinics intervention or to usual care.

SETTING

Nine primary care physician practices that comprise an ambulatory clinic in a large staff-model HMO in western Washington State.

PARTICIPANTS

Those patients aged 65 and older in each practice with the highest risk for being hospitalized or experiencing functional decline.

INTERVENTION

Intervention practices (5 physicians, 96 patients) held half-day Chronic Care Clinics every 3 to 4 months. These clinics included an extended visit with the physician and nurse dedicated to planning chronic disease management; a pharmacist visit that emphasized reduction of polypharmacy and high-risk medications; and a patient self-management/support group. Control practices (4 physicians, 73 patients) received usual care.

MEASUREMENTS

Changes in self-reported urinary incontinence, frequency of falls, depressive symptoms, physical function, and satisfaction were analyzed using an intention-to-treat analysis adjusted for baseline differences, covariates, and practice-level variation. Prescriptions for high-risk medications and cost/utilization data obtained from administrative data were similarly analyzed.

RESULTS

After 24 months, no significant improvements in frequency of incontinence, proportion with falls, depression scores, physical function scores, or prescriptions for high risk medications were demonstrated. Costs of medical care including frequency of hospitalization, hospital days, emergency and ambulatory visits, and total costs of care were not significantly different between intervention and control groups. A higher proportion of intervention patients rated the overall quality of their medical care as excellent compared with control patients (40.0% vs 25.3%, P = .10).

CONCLUSIONS

Although intervention patients expressed high levels of satisfaction with Chronic Care Clinics, improved outcomes for selected geriatric syndromes were not demonstrated. These findings suggest the need for developing greater system-wide support for managing geriatric syndromes in primary care and illustrate the challenges of conducting practice improvement research in a rapidly changing delivery system.

Managed care as a vehicle for delivering more effective chronic care for older persons

Chronic illness is now the dominant feature of health care, and its impact will grow with the aging of the population. Managed care could provide an environment conducive to better care for chronically ill patients. A precondition for these activities is a shift in Medicare payment approaches to managed care organizations to recognize differences in risk. To improve care for the chronically ill, changes need to occur in two major areas: (1) The approach to chronic care needs to become more aggressive, with higher expectations about the benefits from care (even if measured by slowing the rate of decline), and (2) an information infrastructure is needed to help focus clinicians' attention on changes in patients' status. Some of these changes may eventually evolve spontaneously in managed care's search for more efficient ways of meeting its service obligations, but external forces, such as certification and federal mandates, could catalyze the transition.

Outpatient geriatric evaluation and management

OBJECTIVE

To describe the development and operation of a practical model of outpatient geriatric evaluation and management (GEM) for high-risk, community-dwelling older adults.

PARTICIPANTS

Community-dwelling Medicare beneficiaries age 70 years and older who were medically stable but had a high probability of repeated admission to hospitals (P(ra) > .40) in the future (n = 248).

INTERVENTION

Outpatient GEM.

MEASUREMENTS

Demographic, clinical, and use-of-hospital characteristics of patients; nature and quantity of GEM services; satisfaction of patients and their established primary physicians.

RESULTS

At enrollment, the average patient was 78.7 years old, took 5.0 long-term prescription medications and was unable to perform 0.5 (of six) activities of daily living (ADL) and 1.4 (of seven) instrumental ADL. Many patients (71.3%) reported hospital days during the previous year. Each of three interdisciplinary teams (geriatrician, gerontological nurse practitioner, nurse and social worker) performed comprehensive assessments and then provided primary care and case management to a case load of 45 to 52 patients. On average, GEM required 6 months, during which patients visited the GEM clinic 7.4 times, had 10.4 active problems addressed, spoke to GEM staff members weekly by telephone, and were referred to two other providers. Most patients (94.4%) completed the GEM program; 66.7% completed advance directives. Satisfaction with GEM was high among the patients and their established primary physicians. The cost of the GEM personnel averaged about $1540 per patient treated.

CONCLUSIONS

This model of outpatient GEM provided 6 months of targeted intensive care at a reasonable cost. The satisfaction ratings of patients and their primary physicians were high.

Geriatric rehabilitation: state of the art

OBJECTIVES

To provide a clinically useful conceptual framework for the evaluation and treatment of disability in older persons, to review the rehabilitation of common conditions affecting function in older persons, and to discuss the effects of the ongoing changes in the healthcare system on geriatric rehabilitation.

METHODS

MedLine search and review of relevant texts for information on (1) geriatric disability and its treatment, (2) recent high quality research, guidelines, and review articles relevant to the rehabilitation of conditions commonly causing geriatric disability, (3) effects of recent changes in the healthcare system on geriatric rehabilitation.

RESULTS

Several pertinent models for geriatric disability were identified. These are explicated, along with information on the epidemiology of geriatric disability and its causes and relevant clinical applications. Rehabilitation is reviewed for musculoskeletal disorders, stroke and peripheral vascular disease, amputation, cardiopulmonary disorders, hip fracture, and deconditioning. Changes in the healthcare system appear to be affecting geriatric rehabilitation, especially the advent of managed care; relevant articles and opinions are reviewed, along with strategies to accommodate these changes.

CONCLUSIONS

Our understanding of the causes of disability in the older population has improved significantly over the last decade. There has also been noteworthy progress in our knowledge about the effects of selected rehabilitation interventions, especially exercise-related interventions. However, the cost-effectiveness of many rehabilitative interventions remains unclear, particularly for differing patient groups across the continuum of care. More research will be needed to evaluate the effects of managed care on rehabilitation outcomes in older persons.