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Context: Low-income seniors frequently have multiple chronic medical conditions for which they often fail to receive the recommended standard of care. Objectives: To test the effectiveness of a geriatric care management model on improving the quality of care for low-income seniors in primary care. Design, Setting, and Patients: Controlled clinical trial of 951 adults 65 years or older with an annual income less than 200% of the federal poverty level, whose primary care physicians were randomized from January 2002 through August 2004 to participate in the intervention (474 patients) or usual care (477 patients) in community- based health centers. Intervention Patients received 2 years of home-based care management by a nurse practitioner and social worker who collaborated with the primary care physician and a geriatrics interdisciplinary team and were guided by 12 care protocols for common geriatric conditions. Main Outcome Measures The Medical Outcomes 36-ltem Short-Form (SF-36) scales and summary measures; instrumental and basic activities of daily living (ADLs); and emergency department (ED) visits not resulting in hospitalization and hospitalizations. Results Intention-to-treat analysis revealed significant improvements for intervention patients compared with usual care at 24 months in 4 of 8 SF-36 scales: general health (0.2 vs -2.3, P= .045), vitality (2.6 vs -2.6, P< .001), social functioning (3.0 vs -2.3, P=.008), and mental health (3.6 vs-0.3, P=.OO1); and in the Mental Component Summary (2.1 vs -0.3, P< .001). No group differences were found for ADLs or death. The cumulative 2-year ED visit rate per 1000 was lower in the intervention group (1445 [n=474] vs 1748 [n=477], P=.O3) but hospital admission rates per 1000 were not significantly different between groups (700 [n=474] vs 740 [n=477], P=.66). In a predefined group at high risk of hospitalization (comprising 112 intervention and 114 usual-care patients), ED visit and hospital admission rates were lower INSET: Key Components of the Geriatric Resources for Assessment and Care. [ABSTRACT FROM AUTHOR]

Context Depression is a leading cause of functional impairment in elderly individuals and is associated with high medical costs, but there are large gaps in quality of treatment in primary care. Objective To determine the incremental cost-effectiveness of the Improving Mood Promoting Access to Collaborative Treatment (IMPACT) collaborative care management program for late-life depression. Design Randomized controlled trial with recruitment from July 1999 to August 2001. Setting Eighteen primary care clinics from 8 health care organizations in 5 states. Participants A total of 1801 patients 60 years or older with major depression (17%), dysthymic disorder (30%), or both (53%). Intervention Patients were randomly assigned to the IMPACT intervention (n = 906) or to usual primary care (n = 895). Intervention patients were provided access to a depression care manager supervised by a psychiatrist and primary care physician. Depression care managers offered education, support of antidepressant medications prescribed in primary care, and problem-solving treatment in primary care (a brief psychotherapy). Main Outcome Measures Total outpatient costs, depression-free days, and quality-adjusted life-years. Results Relative to usual care, intervention patients experienced 107 (95% confidence interval [CI], 86 to 128) more depression-free days over 24 months. Total outpatient costs were $295 (95% CI, -$525 to $1115) higher during this period. The incremental outpatient cost per depression-free day was $2.76 (95% CI, -$4.95 to $10.47) and incremental outpatient costs per quality-adjusted life-year ranged from $2519 (95% CI, -$4517 to $9554) to $5037 (95% CI, -$9034 to $19 108). Results of a bootstrap analysis suggested a 25% probability that the IMPACT intervention was “dominant” (ie, lower costs and greater effectiveness). Conclusions The IMPACT intervention is a high-value investment for older adults; it is associated with high clinical benefits at a low increment in health care costs. [ABSTRACT FROM AUTHOR]