Evaluation of a primary care nurse case management intervention for chronically ill community dwelling older people

Aim.  The purpose of this study was to test the effectiveness of a collaborative primary care nurse case management intervention emphasising collaboration between physicians, nurses and patients, risk identification, comprehensive assessment, collaborative planning, health monitoring, patient education and transitional care on healthcare utilisation and cost for community dwelling chronically ill older persons. Background.  Primary care teams comprised of nurses and primary care physicians have been suggested as a model for providing quality care to the chronically ill, but this type of intervention has not been systematically evaluated. Design.  A non-randomised, 36 month comparison of two geographically distinct primary care populations was conducted. Methods.  Six hundred and seventy-seven persons aged 65 and older were determined to be at high-risk for mortality, functional decline, or increased health service use. The treatment group (n = 400) received the intervention and the comparison group (n = 277) received usual care. Health plan claims files provided data on number of hospitalisations and bed days, emergency department (ED) visits, physician visits and total cost of care. Results.  After adjustment for baseline variables, there were no significant differences between the treatment and comparison group in the percentage of patients hospitalised or ED visits. However, among those hospitalised in the treatment group, the likelihood of being re-hospitalised was significantly reduced by 34% (p = 0·032). After adjusting for the cost of the intervention, although not statistically significant, the reduced hospital use resulted in cost savings of $106 per patient per month in the treatment group. Conclusions.  The results indicate that a collaborative primary care nurse case management intervention has the potential to be an effective alternative to current primary care delivery system practice. Relevance to clinical practice.  The study suggests that a chronic care intervention emphasising collaboration between physicians, nurses and patients, may be more effective when implemented in integrated provider networks.