Summa Health System, Akron, Ohio, USA.
Popul Health Manag. 2011 Jun;14(3):137-42. doi: 10.1089/pop.2010.0016. Epub 2011 Feb 15.
Interdisciplinary care management is advocated for optimal care of patients with many types of chronic illnesses; however, few models exist that have been tested using randomized trials. The purpose of this report is to describe the theoretical basis for the After Discharge Management of Low Income Frail Elderly (AD-LIFE) trial, which is an ongoing 2-group randomized trial (total n = 530) to test a chronic illness management and transitional care intervention. The intervention is based on Wagner's chronic illness care model and involves comprehensive posthospitalization nurse-led interdisciplinary care management for low income frail elders with chronic illnesses, employs evidence-based protocols that were developed using the Assessing Care of Vulnerable Elders (ACOVE) guidelines, emphasizes patient activation, and integrates with community-based long-term care and other community agencies. The primary aim of the AD-LIFE trial is to test a chronic illness management intervention in vulnerable patients who are eligible for Medicare and Medicaid. This model, with its standardized, evidence-based medical and psychosocial intervention protocols, will be easily transportable to other sites interested in optimizing outcomes for chronically ill older adults. If the results of the AD-LIFE trial demonstrate the superiority of the intervention, then this data will be important for health care policy makers.
跨学科的护理管理被提倡用于优化多种慢性病患者的护理；然而，很少有经过随机试验检验的模式存在。本报告旨在描述低收入虚弱老年人出院后管理（AD-LIFE）试验的理论基础，该试验是一项正在进行的 2 组随机试验（总样本量为 530 名），旨在测试一种慢性病管理和过渡性护理干预措施。该干预措施基于 Wagner 的慢性病护理模式，涉及对患有慢性病的低收入虚弱老年人进行全面的住院后护士主导的跨学科护理管理，采用基于评估弱势群体老年人（ACOVE）指南制定的循证方案，强调患者的积极性，并与社区长期护理和其他社区机构相结合。AD-LIFE 试验的主要目的是在符合医疗保险和医疗补助资格的脆弱患者中测试慢性病管理干预措施。这种模式及其标准化、循证的医疗和心理社会干预方案，将很容易推广到其他有兴趣优化慢性病老年患者结局的地点。如果 AD-LIFE 试验的结果表明干预措施具有优越性，那么这些数据对于医疗保健政策制定者来说将是重要的。
