Expanding Research on Care Coordination for Older Adults: A Discussion of Programs, Methods, and Outcomes

Anne Bozack, MPH; Patricia Volland, MSW, MBA; and Linda Weiss, PhD

Complete list of Articles Reviewed

  1. Albert SM, Simone B, Brassard A, Stern Y, Mayeux R.
    Medicaid home care services and survival in New York City.
    Gerontologist    . 2005;45(5):609-616.

  2. Alkema GE, Wilber KH, Shannon GR, Allen D.
    Reduced mortality: The unexpected impact of a telephone-based care management intervention for older adults in managed care.
    Health Serv Res. 2007;42(4):1632-1650.

  3. Anttila SK, Huhtala HS, Pekurinen MJ, Pitkajarvi TK.
    Cost-effectiveness of an innovative four-year post-discharge programme for elderly patients—Prospective follow-up of hospital and nursing home use in project elderly and randomized controls.
    Scand J Public Health    . 2000;28(1):41-46.

  4. Applebaum R, Straker J, Mehdizadeh S, Warshaw G, Gothelf E.
    Using high-intensity care management to integrate acute and long-term care services: Substitute for large scale system reform?
    Care Manag J    . 2002;3(3):113-119.

  5. Battersby M, Harvey P, Mills PD, et al.
    SA HealthPlus: A controlled trial of a statewide application of a generic model of chronic illness care.
    Milbank Q    . 2007;85(1):37-67.

  6. Béland F, Bergman H, Lebel P, et al.
    A system of integrated care for older persons with disabilities in Canada: Results from a randomized controlled trial.
    J Gerontol A Biol Sci Med Sci    . 2006;61(4):367-373.

  7. Béland F, Bergman H, Lebel P, et al.
    Integrated services for frail elders (SIPA): A trial of a model for Canada.
    Can J Aging    . 2006;25(1):5-42.

  8. Boult C, Rassen J, Rassen A, Moore RJ, Robison S.
    The effect of case management on the costs of health care for enrollees in Medicare Plus Choice plans: A randomized trial.
    J Am Geriatr Soc. 2000;48(8):996-1001.

  9. Boult C, Boult LB, Morishita L, Dowd B, Kane RL, Urdangarin CF.
    A randomized clinical trial of outpatient geriatric evaluation and management.
    J Am Geriatr Soc    . 2001;49(4):351-359.

  10. Boult C, Reider L, Frey K, et al.
    Early effects of "Guided Care" on the quality of health care for multimorbid older persons: A cluster-randomized controlled trial.
    J Gerontol A Biol Sci Med Sci    . 2008;63A(3):321-327.

  11. Brooks MM, Ertl JM.
    Social work home visits: Impact on recidivism and health care costs.
    Continuum Soc Soc Work Leadersh Health Care    . 2000;20(6):3-9.

  12. Browne CV, Braun KL.
    When a case management program closes: Impact as perceived by frail elders and their family caregivers.
    J Appl Gerontol    . 2001;20(3):338-355.

  13. Burton LC, Weiner JP, Stevens GD, Kasper J.
    Health outcomes and Medicaid costs for frail older individuals: A case study of a MCO versus fee-for-service care.
    J Am Geriatr Soc. 2002;50(2):382-388.

  14. Campbell J, Aday RH.
    Benefits of a nurse-managed wellness program. A senior center model using community-based sites for older adult intervention and self-care activities may promote an ability to maintain an independent lifestyle.
    J Gerontol Nurs. 2001;27(3):34-43.

  15. Chang C, Jackson SS, Bullman TA, Cobbs EL.
    Impact of a home-based primary care program in an urban Veteran's Affairs medical center.
    J Am Med Dir Assoc. 2009;10(2):133-137.

  16. Cheung C, Man-hung Ngan R.
    Improving older adults' functional ability through service use in a home care program in Hong Kong.
    Res Soc Work Pract    . 2005;15(3):154-164.

  17. Cohen HJ, Feussner JR, Weinberger M, et al.
    A controlled trial of inpatient and outpatient geriatric evaluation and management    .
    N Engl J Med    . 2002;346(12):905-912.

  18. Coleman EA, Eilertsen TB, Kramer AM, Magid DJ, Beck A, Conner D.
    Reducing emergency visits in older adults with chronic illness. A randomized, controlled trial of group visits.
    Eff Clin Pract. 2001;4(2):49-57.

  19. Counsell SR, Callahan CM, Tu W, Stump TE, Arling GW.
    Cost analysis of the Geriatric Resources for Assessment and Care of Elders care management intervention    .
    J Am Geriatr Soc. 2009;57(8):1420-1426.

  20. Counsell SR, Callahan CM, Clark DO, et al.
    Geriatric care management for low-income seniors: A randomized controlled trial    .
    JAMA    . 2007;298(22):2623-2633.

  21. Dellasega CA, Salerno FA, Lacko LA, Wasser TE.
    The impact of a geriatric assessment team on patient problems and outcomes.
    Medsurg Nurs. 2001;10(4):202-209.

  22. 22. Dorr DA, Wilcox AB, Brunker CP, Burdon RE, Donnelly SM.
    The effect of technology-supported, multidisease care management on the mortality and hospitalization of seniors    .
    J Am Geriatr Soc. 2008;56(12):2203-2210.

  23. Duke C.
    The frail elderly community-based case management project.
    Geriatr Nurs    . 2005;26(2):122-127.

  24. Duke DC, Genge T.
    Community-based health care for frail seniors: Development and evaluation of a program.
    Geriatr Aging    . 2009;12(8):414-418.

  25. Elwyn G, Williams M, Roberts C, Newcombe RG, Vincent J.
    Case management by nurses in primary care: Analysis of 73 'success stories'    .
    Qual Prim Care    . 2008;16(2):75-82.

  26. Enguidanos SM, Jamison PM.
    Moving from tacit knowledge to evidence-based practice: The Kaiser Permanente community partners study for older adults    .
    Home Health Care Serv Q    . 2006;25(1-2):13-31.

  27. Fischer LR, Green CA, Goodman MJ, et al.
    Community-based care and risk of nursing home placement.
    Med Care    . 2003;41(12):1407-1416.

  28. Fisher HM, McCabe S.
    Managing chronic conditions for elderly adults: The VNS CHOICE model.
    Health Care Financ Rev    . 2005;27(1):33-45.

  29. Gillette PD, Wiegand M, Pariser D, et al.
    Interdisciplinary geriatric assessment and self-management intervention improves function in community-dwelling older adults    .
    J Geriatr Phys Ther    . 2006;29(3):131-132.

  30. Gravelle H, Dusheiko M, Sheaff R, et al.
    Impact of case management (Evercare) on frail elderly patients: Controlled before and after analysis of quantitative outcome data.
    BMJ    . 2007;334(7583):31-34.

  31. Hammer BJ.
    Community-based case management for positive outcomes    .
    Geriatr Nurs    . 2001;22(5):271-275.

  32. Hébert R, Raîche M, Dubois MF, Gueye NR, Dubuc N, Tousignant M.
    Impact of PRISMA, a coordination-type integrated service delivery system for frail older people in Québec (Canada): A quasi-experimental study.
    J Gerontol B Psychol Sci Soc Sci    . 2010;65B(1):107-118.

  33. Hébert R, Robichaud L, Roy P, Bravo G, Voyer L.
    Efficacy of a nurse-led multidimensional preventive programme for older people at risk of functional decline. A randomized controlled trial.
    Age Ageing    . 2001;30(2):147-153.

  34. Hogg W, Lemelin J, Dahrouge S, et al.
    Randomized controlled trial of anticipatory and preventive multidisciplinary team care for complex patients in a community-based primary care setting.
    Can Fam Physician. 2009;55(12):e76-85.

  35. Hughes SL, Finkel S, Harter K, Fulton B, Edelman P, Waters T.
    Evaluation of the managed community care demonstration project.
    J Aging Health. 2003;15(1):246-268.

  36. Jiwa M, Gerrish K, Gibson A, Scott H.
    Preventing avoidable hospital admission of older people    .
    Br J Community Nurs. 2002;7(8):426-431.

  37. Kane RL, Homyak P, Bershadsky B, Flood S.
    The effects of a variant of the Program for All-inclusive Care of the Elderly on hospital utilization and outcomes.
    J Am Geriatr Soc. 2006;54(2):276-283.

  38. Landi F, Onder G, Russo A, et al. New model of integrated home care for the elderly: Impact on hospital use.
    J Clin Epidemiol. 2001;54:968-970.

  39. Leung AC, Liu C, Chow NW, Chi I.
    Cost-benefit analysis of a case management project for the community-dwelling frail elderly in Hong Kong.
    J Appl Gerontol    . 2004;23(1):70-85.

  40. Long MJ, Marshall BS.
    What price an additional day of life? A cost-effectiveness study of case management    .
    Am J Manag Care. 2000;6(8):881-886.

  41. Lowenstein A.
    A case management demonstration project for the frail elderly in Israel    .
    Care Manage J    . 2000;2(1):5-14.

  42. Lyon D, Miller J, Pine K.
    The Castlefields integrated care model: The evidence summarised    .
    J Integr Care    . 2006;14(1):7-12.

  43. Marek KD, Popejoy L, Petroski G, Mehr D, Rantz M, Lin W.
    Clinical outcomes of aging in place    .
    Nurs Res    . 2005;54(3):202-211.

  44. Marek KD, Popejoy L, Petroski G, Rantz M.
    Nurse care coordination in community-based long-term care    .
    J Nurs Scholarsh    . 2006;38(1):80-86.

  45. Markle-Reid M, Weir R, Browne G, Roberts J, Gafni A, Henderson S.
    Health promotion for frail older home care clients    .
    J Adv Nurs    . 2006;54(3):381-395.

  46. Martin DC, Berger ML, Anstatt DT, et al.
    A randomized controlled open trial of population-based disease and case management in a Medicare plus choice health maintenance organization    .
    Prev Chronic Dis    . 2004;1(4):A05.

  47. McAtee RE, Crandall D, Wright LD, Beverly CJ.
    Senior health clinics: Are they financially viable?
    J Am Geriatr Soc. 2009;57(7):1293-1299.

  48. McWilliam CL, Stewart M, Vingilis E, et al.
    Flexible client-driven in-home case management: An option to consider    .
    Care Manage J    . 2004;5(2):73-86.

  49. Melis RJ, Adang E, Teerenstra S, et al.
    Cost-effectiveness of a multidisciplinary intervention model for community-dwelling frail older people    .
    J Gerontol A Biol Sci Med Sci    . 2008;63(3):275-282.

  50. Miller P, Gladman JR, Cunliffe AL, Husbands SL, Dewey ME, Harwood RH.
    Economic analysis of an early discharge rehabilitation service for older people.
    Age Ageing    . 2005;34(3):274-280.

  51. Mitton C, O'Neil D, Simpson L, Hoppins Y, Harcus S.
    Nurse-physician collaborative partnership: A rural model for the chronically ill    .
    Can J Rural Med. 2007;12(4):208-216.

  52. Montgomery PR, Fallis WM.
    South Winnipeg integrated geriatric program (SWING): A rapid community-response program for the frail elderly    .
    Can J Aging    . 2003;22(3):275-281.

  53. Morales-Asencio JM, Gonzalo-Jimenez E, Martin-Santos FJ, et al.
    Effectiveness of a nurse-led case management home care model in primary health care. A quasi-experimental, controlled, multi-centre study    .
    BMC Health Serv Res    . 2008;8:193.

  54. Mukamel DB, Temkin-Greener H, Delavan R, et al.
    Team performance and risk-adjusted health outcomes in the Program of All-Inclusive Care for the Elderly (PACE)    .
    Gerontologist    . 2006;46(2):227-237.

  55. Nadash P.
    Two models of managed long-term care: Comparing PACE with a Medicaid-only plan    .
    Gerontologist    . 2004;44(5):644-654.

  56. Nelson JM, Arnold-Powers P.
    Community case management for frail, elderly clients.
    J Nurs Adm    . 2001;31(9):444-450.

  57. Newcomer R, Maravilla V, Faculjak P, Graves MT.
    Outcomes of preventive case management among high-risk elderly in three medical groups: A randomized clinical trial.
    Eval Health Prof. 2004;27(4):323-348.

  58. Noel HC, Rogers E, Vogel DC, Rohrbaugh RM.
    Linking case management, healthy outcomes and resource use across the continuum.
    Care Management    . 2004;10(1):20.

  59. Ollonqvist K, Aaltonen T, Karppi S, Hinkka K, Pöntinen S.
    Network-based rehabilitation increases formal support of frail elderly home-dwelling persons in Finland: Randomised controlled trial.
    Health Soc Care Community. 2008;16(2):115-125.

  60. Onder G, Liperoti R, Bernabei R, Landi F.
    Case management, preventive strategies, and caregiver attitudes among older adults in home care: Results of the ADHOC study    .
    J Am Med Dir Assoc    . 2008;9(5):337-341.

  61. Patrick H, Roberts N, Hutt R, Hewitt P, Connelly J, Oliver D.
    Evaluation of innovations in nursing practice: Report and discussion    .
    Br J Nurs. 2006;15(9):520-523.

  62. Phelan EA, Williams B, Penninx BWJ, LoGerfo JP, Leveille SG.
    Activities of daily living function and disability in older adults in a randomized trial of the health enhancement program. J
    Gerontol A Biol Sci Med Sci    . 2004;59A(8):838-843.

  63. Phelan EA, Balderson B, Levine M, et al.
    Delivering effective primary care to older adults: A randomized controlled trial of the senior resource team at Group Health Cooperative    .
    J Am Geriatr Soc    . 2007;55(11):1748-1756.

  64. Phillips SL, Phillips JV, Branaman-Phillips J, Miller DJ.
    Geriatric versus non-geriatric approach of care to moderate PRA risk senior population    .
    J Am Med Dir Assoc. 2005;6(6):396-399.

  65. Ritchie C, Wieland D, Tully C, Rowe J, Sims R, Bodner E.
    Coordination and Advocacy for Rural Elders (CARE): A model of rural case management with veterans    .
    Gerontologist    . 2002;42(3):399-405.

  66. Sargent P, Pickard S, Sheaff R, Boaden R.
    Patient and carer perceptions of case management for long-term conditions    .
    Health Soc Care Community. 2007;15(6):511-519.

  67. Schraeder C, Shelton P, Sager M.
    The effects of a collaborative model of primary care on the mortality and hospital use of community-dwelling older adults    .
    J Gerontol A Biol Sci Med Sci    . 2001;56(2):M106-12.

  68. Schraeder C, Fraser CW, Clark I, et al.
    Evaluation of a primary care nurse case management intervention for chronically ill community dwelling older people    .
    J Clin Nurs. 2008;17(11):407-417.

  69. Shannon GR, Wilber KH, Allen D.
    Reductions in costly healthcare service utilization: Findings from the care advocate program.
    J Am Geriatr Soc    . 2006;54(7):1102-1107.

  70. Sheaff R, Boaden R, Sargent P, et al.
    Impacts of case management for frail elderly people: A qualitative study.
    J Health Serv Res Policy. 2009;14(2):88-95.

  71. Sledge WH, Brown KE, Levine JM, et al.
    A randomized trial of primary intensive care to reduce hospital admissions in patients with high utilization of inpatient services    .
    Dis Management    . 2006;9(6):328-338.

  72. Sommers LS, Marton KI, Barbaccia JC, Randolph J.
    Physician, nurse, and social worker collaboration in primary care for chronically ill seniors.
    Arch Intern Med. 2000;160(12):1825-1833.

  73. Stock R, Mahoney ER, Reece D, Cesario L.
    Developing a senior healthcare practice using the chronic care model: Effect on physical function and health-related quality of life    .
    J Am Geriatr Soc    . 2008;56(7):1342-1348.

  74. Stock RD, Reece D, Cesario L.
    Developing a comprehensive interdisciplinary senior healthcare practice    .
    J Am Geriatr Soc    . 2004;52(12):2128-2133.

  75. Stuart B, D'Onofrio CN, Boatman S, Feigelman G.
    CHOICES: Promoting early access to end-of-life care through home-based transition management.
    J Palliat Med    . 2003;6(4):671-683.

  76. Stuck AE, Minder CE, Peter-Wuest I, et al.
    A randomized trial of in-home visits for disability prevention in community-dwelling older people at low and high risk for nursing home admission    .
    Arch Intern Med. 2000;160(7):977-986.

  77. Sylvia ML, Griswold M, Dunbar L, Boyd CM, Park M, Boult C.
    Guided Care: Cost and utilization outcomes in a pilot study    .
    Dis Management. 2008;11(1):29-36.

  78. Tan EJ, Lui L, Eng C, Jha AK, Covinsky KE.
    Differences in mortality of black and white patients enrolled in the Program of All-inclusive Care for the Elderly.
    J Am Geriatr Soc. 2003;51(2):246-251.

  79. Tourigny A, Durand PJ, Bonin L, Hebert R, Rochette L.
    Quasi-experimental study of the effectiveness of an integrated service delivery network for the frail elderly.
    Can J Aging    . 2004;23(3):231-246.

  80. van Hout HP, Jansen AP, van Marwijk HW, Pronk M, Frijters DF, Nijpels G.
    Prevention of adverse health trajectories in a vulnerable elderly population through nurse home visits: A randomized controlled trial.
    J Gerontol A Biol Sci Med Sci    . 2010;65(7):734-742.

  81. Vass M, Avlund K, Kvist K, Hendriksen C, Andersen CK, Keiding N.
    Structured home visits to older people. Are they only of benefit for women? A randomised controlled trial    .
    Scand J Prim Health Care    . 2004;22(2):106-111.

  82. Vass M, Avlund K, Lauridsen J, Hendriksen C.
    Feasible model for prevention of functional decline in older people: Municipality-randomized, controlled trial.
    J Am Geriatr Soc. 2005;53(4):563-568.

  83. Vedel I, De Stampa M, Bergman H, et al.
    A novel model of integrated care for the elderly: COPA, coordination of professional care for the elderly    .
    Aging Clin Exp Res. 2009;21(6):414-423.

  84. Weuve JL, Boult C, Morishita L.
    The effects of outpatient geriatric evaluation and management on caregiver burden    .
    Gerontologist    . 2000;40(4):429-436.

  85. Wieland D, Boland R, Baskins J, Kinosian B.
    Five-year survival in a Program of All-inclusive Care for Elderly compared with alternative institutional and home- and community-based care    .
    J Gerontol A Biol Sci Med Sci    . 2010;65(7):721-726.