title: Complex chronic care patients managed using hospice model.
abstract: Some patients just defy the traditional disease management model. Many are elderly, have complex medical needs, and find comfort in their frequent visits to the hospital emergency department. Find out how a pilot DM program is using hospice and home health care providers as partners to help manage CHF and COPD among the high-cost elderly, and how the DM approach maintains its effectiveness even in the patients' final days.
mesh_terms: D002140:California; D002908:Chronic Disease / Q000523:psychology; D019468:Disease Management; D006279:Health Maintenance Organizations / Q000458:organization & administration*; D006333:Heart Failure; D017051:Hospice Care / Q000458:organization & administration* / Q000523:psychology; D006801:Humans; D017146:Models, Organizational; D018802:Patient-Centered Care; D010865:Pilot Projects