Postdischarge Care Management Integrates Medical and Psychosocial Care of Low-Income Elderly Patients

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Snapshot

Related Profile: Cooperative Network Improves Patient Transitions Between Hospitals and Skilled Nursing Facilities, Reducing Readmissions and Length of Hospital Stays

Summary

A postdischarge, interdisciplinary care management program integrates medical and social care for low-income elderly patients with chronic illnesses. A pilot study conducted at Summa Care, a provider-sponsored health plan for Summa Health System, found that 70 percent of participants reported improved health, and 93 percent rated their experience as good or excellent 1 year after beginning participation in the program. The program also achieved savings of approximately $600 to $1,000 per patient per month as a result of fewer hospitalizations. The organization is currently conducting a 3-year randomized controlled trial to confirm these benefits.

Evidence Rating

Moderate: The evidence derived from a before and after analysis consists of self-reported data on health improvements and patient satisfaction, along with pre- and post-implementation comparisons of hospital admissions. A 3-year randomized controlled trial (RCT) is under way to more rigorously evaluate this program.

Developing Organizations

Summa Health System
Summa Health System and Summa Care, Inc., are located in Akron, OH.

Date First Implemented

2000

Patient Population

Age > Aged adult (80 + years); Vulnerable Populations > Frail elderly; Impoverished; Medically or socially complex; Insurance Status > Medicare; Age > Senior adult (65-79 years)

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