I am looking for evidence on the application/utilization of the Chronic Care Model in geriatric care, in particular in the reactivation trajectory after hospital discharge (e.g. somatic unit, PG unit, transfer unit).
You might be interested in our adaptation of Eric Coleman's Care Transition Intervention in an intermediate care unit in Australia. The full text of the study protocol is available from my profile page. The publication is entitled 'Coaching Older Adults and their carers to have their preferences heard: a randomised controlled trial in an intermediate care setting'. Our study participants had a mean age of 84 years and more than 40% had cognitive impairment. For this reason, we asked participants to nominate a caregiver (most often a family member) who could also be present at meetings with a geriatrician and specialist aged care nurse. The intervention was a health literacy and coaching intervention and utilised a question prompt list to encourage participation and an audio-recording of the meeting with the geriatrician as a memory aid. We aimed to provide participants and carers with information about the older person's medical conditions and medications and 'red flags' indicative of a deterioration in the older person's health status and prepare carers for an advocacy role during future care transitions. I think you will find many areas of congruence with the Chronic Care Model. Best regards, Stacey
Thanks for your reply. Thus far, I have not come across any intervention for geriatric reactivation care using the CCM. I will look with great interest into the protocol.
Hi Annemarie,
You might also be interested in looking at the Coordinated Veterans' Care (CVC) Program which was introduced for Gold Card Holders in Australia in May 2011. Information is available at:
http://www.dva.gov.au/health_and_wellbeing/health_programs/cvc/Pages/default.aspx
The program targets veterans with one or more chronic conditions who are at high risk of hospital (re)admission. Eligible veterans register with their general practice and consent to information sharing between health care professionals. A comprehensive needs assessment is undertaken by a practice nurse or GP and the patient is encouraged to establish a personal medium term health goal and to participate in the development of a care plan. The training program is based on the Flinders Program for Chronic Condition Self-Management which is underpinned by the CCM. GPs receive periodic payments for care coordination (which includes patient coaching) and it is expected that practice nurses are in contact with patients at least once every 28 days, The program has enrolled more than 10,000 veterans and is currently being evaluated.
When an enrolled patient is hospitalised, practice nurses are encouraged to contribute to discharge planning and to provide follow-up soon after discharge. This is a new model of care for general practice and it will be interesting to see how the program is working on the ground once the evaluation is complete.
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