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Service Delivery Innovation Profile

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

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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 finished a 3-year randomized controlled trial to confirm these benefits and the results will be published soon.

Evidence Rating (What is this?)

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) was completed to more rigorously evaluate this program; results will be published soon.
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Developing Organizations

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

Date First Implemented

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Patient Population

Age > Aged adult (80 + years); Vulnerable Populations > Frail elderly; Impoverished; Age > Senior adult (65-79 years)end pp

Problem Addressed

Older adult patients with chronic diseases benefit when both their social and medical needs are met through interdisciplinary care management programs. However, most existing programs focus on meeting one of these two needs (either social or medical), not both. As a result, older adult patients with chronic diseases who are discharged from the hospital often fail to receive the thorough, coordinated services required to prevent repeat hospitalizations.
  • Lack of medical/social care integration in chronic care management programs: Although disease management programs exist for many chronic illnesses, most have a predominantly medical or social focus, with little integration across these areas.1
  • Poor transitional care: Patients undergoing transitions often face deficiencies in the quality of care, including insufficient education about self-management of their condition, conflicting advice regarding care, and a lack of an identified provider who can monitor their case during the transition.2
  • Poorer outcomes, higher costs: Deficiencies in transitional care lead to higher costs, medical errors, and poor compliance with medications.3,4

What They Did

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Description of the Innovative Activity

Summa Health System developed a program called the Frail Elders Care Management Program in which interdisciplinary teams of caregivers provide integrated medical and social care management to low-income elderly inpatients with chronic illnesses using evidence-based protocols and regular evaluation after hospital discharge. The goal of the program, which ran from 2000 to 2003, was to facilitate the transition from hospital to home, ensure optimal preventive care, quickly identify new medical and social issues, and avoid rehospitalizations and functional decline. Key elements of the program are described below:
  • Screening for eligible patients: The program identified older adult patients who were high utilizers of Summa Health System emergency department (ED) and/or hospital services. Using a simple screening form (the Risk Appraisal Tool), nurses screened patients over the telephone or in person at the hospital or skilled nursing facility to determine whether care management services could improve quality of care and decrease costs.
  • Initial contact: Once patients were deemed to be potentially eligible for program participation, they were contacted by one of the program's advanced practice nurses; the nurse explained the program and asked if they could visit the patients to do an assessment.
  • Assessment for program participation: Advanced practice nurses visited the patients at home, in the hospital, or in the skilled nursing facility to perform the assessment. The nurses used a Risk Appraisal Tool that assessed the following patient characteristics: confusion/cognitive impairment, difficulty with ambulating/self-care, fall(s) occurring within the past 2 months, lives alone/lacks caregiver, ED/hospital visit(s) within the past 60 days, taking five or more medications, or nurse/social worker recommendation. Typical program participant characteristics were as follows:
    • 65 years of age or older (97 percent of participants)
    • Common medical diagnoses: chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, cerebrovascular accident, hypertension, diabetes, osteoarthritis, and osteoporosis. An analysis of enrollees showed that 10 percent of enrollees had previously suffered a stroke.
    • Impaired activities of daily living or impaired instrumental activities of daily living. Analysis shows that most participants had activities of daily living deficits, including 40 percent with deficits related to bathing and ambulation and 25 percent with deficits related to dressing.
    • Overall, 92 percent of patients had at least one medical or social issue that required an intervention. For example, more than one-half of patients took between 5 and 10 prescriptions, while 37 percent took more than 10 prescriptions. Approximately 40 percent of patients lived alone, 26 percent had memory impairment, 55 percent tested positive on a depression screen, 47 percent had experienced one or more falls, 43 percent had incontinence, 41 percent had sleep disturbance, 25 percent had nutrition problems, and 13 percent had skin problems.
  • Interdisciplinary care plan development: After the initial assessment, an interdisciplinary team meeting was convened to review the patient's circumstances and develop a care plan. The core members include the geriatrician, the advanced practice nurse, a registered nurse care manager, a social worker, and a geriatric pharmacist. Other clinicians were called on as needed, including medical consultants in various specialties (e.g., pulmonology, cardiology, psychiatry, physical/occupational therapy). The team developed a care plan identifying problems and recommendations.
  • Care plan implementation: The registered nurse care manager assumed responsibility for implementing the patient's care plan. Care managers were assigned to specific primary care practices so that they could build relationships with practice physicians and staff members, easily and efficiently discuss patients, and ensure that recommendations were implemented swiftly.
  • Primary care physician (PCP) involvement: The registered nurse care manager met with the patient's PCP to review the recommendations, obtain input from the PCP, and ensure that no care plan elements were contraindicated. PCPs were paid a one-time fee for a plan-of-care meeting, based on a typical 15- to 20-minute office visit. PCPs and registered nurse care managers interacted as needed on an ongoing basis to review and modify care plan.
  • Ongoing contact with patient: The care plan was sent to the patient along with instructions on self-management. A triage schedule based on patient acuity delineated the number and types of contact the registered nurse care manager initiated with the patient. Home visits were made as needed.
  • Participation in physician office visits: Registered nurse care managers attended PCP office visits with the patients, acted as "health translators" during visits with subspecialists, and ensured thorough and accurate transfer of information among caregivers.
  • Patient education: The RN care managers provided patient education about their conditions, including self-care skills. Some examples of education given include avoiding "triggers" that can cause exacerbations, diet plans, physical activity suggestions, compliance with medications, and recommended follow up care and patient–physician communication. This education occurred in any of several settings, including over the phone, in the PCP office, and/or during home visits.
  • Monitoring: The registered nurse care manager assessed patient compliance with the care plan; alerted the PCP and the advanced practice nurse to significant changes in the patient's condition; communicated with the PCP regarding the patient's progress vis-a-vis desired outcomes; collaborated with other providers, including home care, acute care, nursing facility, and community agencies; and solicited assistance from the geriatrician when needed.
  • Collaboration with community agency case managers: Collaboration was informal; for example, if the patient was involved with Ohio's Pre-Admission Screening System Providing Options and Resources Today (PASSPORT) Medicaid waiver program, the advanced practice nurse would alert the PASSPORT care manager of the patient's participation in the care program.
The Frail Elders Care Management program served 1,272 patients over 3 years. Based on positive results, Summa Health System conducted an Agency for Healthcare Research and Quality (AHRQ)–funded 3-year random control trial (#1R01HSO14539-01A1) on a no-cost extension to measure program outcomes. This trial enrolled 530 subjects out of a targeted sample size of 530. Data analysis from the trial is complete and the results will be submitted for publication soon.

Context of the Innovation

Summa Health System is a 963-bed nonprofit health care delivery network in Ohio with 3 community teaching hospitals, more than 50,000 admissions, 100,000 ED visits, and 500,000 outpatient visits per year.

Summa's geriatrics division has been promoting interdisciplinary care for over a decade. In the early 1990s, Summa Health developed an Acute Care for Elders Model that integrated the principles of geriatric assessment and continuous quality improvement as part of an RCT. The Acute Care for Elders Model was first implemented in Summa Health's Akron City Hospital in one unit in 1994. An earlier RCT conducted at the University Hospitals in Cleveland had indicated that the Acute Care for Elders Model improved activities of daily living function; decreased discharge to long-term care; improved patient, nurse, and physician satisfaction; and improved care processes at no added expense to the hospital.

When Summa developed a Medicare risk (Medicare Advantage) insurance product—called SummaCare Secure—in 1996, the product incorporated a health risk assessment component. However, the component included recommendations for improving care but little or no case/care management, and the Medicare Advantage product expenses and utilization continued to increase. Because Medicare length of stay on the Acute Care for Elders unit was consistently lower (by approximately 0.5 days) than for other Medicare patients, SummaCare Secure requested that all medical admissions of enrolled patients be made to the Acute Care for Elders unit. However, to accommodate all these patients, the Acute Care for Elders Model's implementation would have to be expanded.

The successes of the Acute Care for Elders Model and the need to improve utilization management for SummaCare Secure spurred Summa leadership to create a team including health plan, hospital, and senior services representatives to develop an expanded senior care management program, which would identify at-risk members proactively and reactively at all entry points; follow patients over time and across settings; ensure coordinated information sharing; blend clinical decisionmaking with utilization management; promote interdisciplinary care management; and improve patient outcomes while decreasing health care expenses. The team created a "Frail Elder Care Management Program" to meet these objectives.

Did It Work?

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Results of an analysis of a subset of 118 of 1,272 participants indicate that the program improved health status and reduced hospitalizations, leading to high levels of patient and physician satisfaction.
  • Reported health improvements: Approximately 70 percent of patients believe the program improved their health, made it easier for them to get health care services, and provided them with a better understanding of their disease. No participant reported a decline in health status over the 1-year program period.
  • Decreased costs: Hospital admissions per 1,000 participants dropped by between 10 and 20 percent, yielding estimated cost savings of roughly $600 to $1,000 per participant per month. However, because of "regression to the mean," the true cost savings is difficult to determine. Thus, innovators wanted to attempt a randomized controlled trial to evaluate the impact of the model on quality of care and cost-effectiveness.
  • High satisfaction: Ninety-two percent of participants said they would recommend the program, and 93 percent rated their experience in the program as good or excellent. In a physician satisfaction survey asking whether the program facilitated the ability to care for complex senior patients, 81 percent responded "most definitely," "yes," or "somewhat," whereas 17 percent were unsure.

Evidence Rating (What is this?)

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) was completed to more rigorously evaluate this program; results will be published soon.

How They Did It

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Planning and Development Process

Key steps in the planning and development process include the following:
  • Enlisting clinician support: The geriatrician head of the program talked to department chairpersons and attended department and family medicine and internal medicine resident meetings to give a 5-minute presentation about the Frail Elder Care Management Program and how it would work, highlight the one-time payment, and present data on successes with the Acute Care for Elders model.
  • Hiring and training care managers: Care managers were hired and trained regarding details of the care model.
    • Hiring: Each care manager was interviewed and assessed first for interpersonal skills, because they are important in establishing trust and a therapeutic relationship with patients; second for their experience with older adults; and third for their ability to effectively interface with PCPs.
    • Training: Each care manager was paired with an advanced practice nurse certified in geriatrics. Learning was case based. The care managers went with the advanced practice nurse on home visits and were provided with education regarding common geriatric syndromes, functional assessment, and medications. Ongoing learning occurred during weekly interdisciplinary care meetings during which new patients as well as review patients were presented to the team.
  • Partnership with Area Agency on Aging: Over the past 10 years, the Summa Health System geriatrics department has been cultivating its relationship with the Area Agency on Aging, which is the manager of the Ohio Medicaid Waiver community-based long-term care program (PASSPORT). The agency executive director worked with Summa's lead geriatrician to promote the integration of the biomedical and psychosocial model of care. The goal was to foster collaboration between PASSPORT and Frail Elder Care Management Program care managers and ensure that all resources are coordinated. By incorporating coordination with community agencies, the Frail Elder Care Management Program helped tighten this relationship.
  • Initial pilot test: The geriatrics department developed the program and tested it during a pilot trial of 1,272 patients over 3 years. Based on successful results from the trial, the program obtained grant funding from the AHRQ to test the program in an RCT.

Resources Used and Skills Needed

  • Staffing levels: The program implementation incorporated a caseload of 50 to 60 patients per care manager and 120 to 150 patients per social worker. However, depending on patient acuity and functionality, caseload may vary. As part of the RCT, advanced practice nurses and registered nurse care managers are keeping a "manpower" log that tracks the time involved in 13 different groupings of tasks to better inform staffing levels.
  • Required staff skills: Advanced practice nurses generally have a Master of Science Degree in Nursing; certification as a Clinical Nurse Specialist or Nurse Practitioner in Gerontology through the American Nurses Credentialing Center; at least 2 to 3 years experience in geriatrics in an outpatient setting, with at least 1 year involving some form of care management; a working knowledge of community resources; a very outgoing personality (which is critical to establishing relationships with patients and PCPs); an ability to work collaboratively on an interdisciplinary team; and an ability to lead and motivate others in a team. Registered nurse case managers generally have a Bachelor of Science degree in Nursing; geriatrics certification or care management certification (this is desired but not required); at least 2 to 3 years experience in geriatrics in an outpatient or home care setting, with at least 1 year involved in some form of care management; a working knowledge of community resources; and an outgoing personality and good communication skills.
  • Costs: The primary costs involve salaries and benefits for the advanced practice nurses and registered nurse case managers; overall program costs are not available.
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Funding Sources

Agency for Healthcare Research and Quality; Summa Health System
  • The program was funded internally by SummaCare Health Plan.
  • The randomized control trial was funded by AHRQ grant #1R01HSO14539-01A1.
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Tools and Other Resources

The AHRQ Resource Page on System Design can be found at

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Adoption Considerations

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Getting Started with This Innovation

  • Provide vision for why care coordination is important for patients, caregivers, and providers.
  • Link concept to the institution's mission and values.
  • Develop a strong business plan and secure a commitment of resources sufficient to get the program started when the return on investment may not be apparent.
  • Make a concerted effort to explain the program to PCPs and to win their support; emphasize how Medicare reimbursement can compensate these physicians for their time, at least minimally, to convey that their input is valued.
  • Expect case management to be very intensive during the first 3 months of the program, as patients are educated about their disease and how to communicate effectively with physicians.

Sustaining This Innovation

  • Involve the PCP in the ongoing development and refinement of the care plan, both to improve the plan and prevent the PCP from feeling "forced" to implement the recommendations.
  • Coordinate with other care managers from community agencies (e.g., PASSPORT) who may be involved with these patients, which helps to ensure seamless care.

Additional Considerations

  • Summa Health was able to work on another RCT aimed at improving advanced chronic illness planning with the patient and PCP due to the first project's success. This RCT enrolled community-based long-term care waiver subjects after initial admission and enrollment into the PASSPORT program (Ohio's community-based long-term care waiver program), called the PEACE trial (Promoting Effective Advance Care for Elders). Summa Health received a small prepilot grant from Summa Health System Foundation and have submitted for an RCT pilot from the National Palliative Care Research Center. Summa Health is also doing this project through partnership and collaboration with the local Area Agency on Aging.

More Information

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Contact the Innovator

Kyle R. Allen, DO, AGSF
Medical Director Geriatric Medicine and LifeLong Health
Riverside Health System
Lifelong Health & Aging Related Services Administration
1020 Old Denbigh Blvd., Suite 1020A
Newport News, VA 23602
Office: (757)- 875-7539
Fax: (757)-875-2070

Carolyn Holder MSN, RN GCNS-BC
Director, Transitional Care and Utilization Management
Summa Health System
525 East Market Street
Akron, Ohio 44309
Phone: 330-375-7784
Fax: 330-375-6508

Kathy Wright, PhD, RN
Summa Health System
75 Arch Street
Suite G1
Akron, OH 44304
Phone: (330) 375-3051

Sue Hazelett, RN, MS
Summa Health System
75 Arch Street
Suite G1
Akron, OH 44304
Phone: (330) 375-3051

Innovator Disclosures

Dr. Allen, Ms. Holder, and Ms. Wright have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

Ms. Hazelett reported having no financial interests or business/professional affiliations relevant to the work described in the profile other than the funders listed in the Funding Sources section.

References/Related Articles

Wright K, Hazelett S, Jarjoura D, et al. The AD-LIFE trial: working to integrate medical and psychosocial care management models. Home Healthc Nurse. 2007;25(5):308-14. [PubMed]

Landefeld CS, Palmer RM, Kresevic DM, et al. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med. 1995;332(20):1338-44. [PubMed]


1 Wright K, Hazelett S, Jarjoura D, et al. The AD-LIFE trial: working to integrate medical and psychosocial care management models. Home Healthc Nurse. 2007;25(5):308-14. [PubMed]
2 Coleman EA, Parry C, Chalmers S, et al. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822-8. [PubMed]
3 Boockvar K, Fishman E, Kyriacou CK, et al. Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities. Arch Intern Med. 2004;164(5):545-50. [PubMed]
4 Moore C, Wisnivesky J, Williams S, et al. Medical errors related to the discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18(8):646-51. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 18, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: November 09, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.