title: The AD-LIFE trial: working to integrate medical and psychosocial care management models.
abstract: Interdisciplinary care management that fully integrates medical and social care is advocated for optimal care of patients with many types of chronic illnesses, yet the effectiveness of this care model has been insufficiently tested using randomized controlled trials. This article presents the results of a pilot care management program and a description of a larger randomized controlled trial modeled after the pilot program (the After Discharge Care Management of Low-Income Frail Elderly [AD-LIFE] trial). It compares an integrated medical and social care management model (intervention group) with a purely social model (control group) involving low-income elderly patients with chronic conditions and functional impairment at high risk for rehospitalization or nursing home placement. A case study of a patient participant in the AD-LIFE study is presented. The case illustrates the positive effects of the intervention on biopsychosocial outcomes.
authors.affiliation: Summa Center for Senior Health and Care Coordination Program, Summa Health System, 41 Arch Street, Akron, OH 44304, USA.
authors.forename: Kathy
authors.initials: K
authors.lastname: Wright
authors.forename: Susan
authors.initials: S
authors.lastname: Hazelett
authors.forename: David
authors.initials: D
authors.lastname: Jarjoura
authors.forename: Kyle
authors.initials: K
authors.lastname: Allen
mesh_terms: D000359:Aftercare / Q000458:organization & administration*; D000368:Aged; D003266:Continuity of Patient Care / Q000458:organization & administration; D019468:Disease Management; D005260:Female; D016330:Frail Elderly; D015577:Geriatric Assessment; D006299:Health Services for the Aged / Q000458:organization & administration*; D006699:Home Care Services / Q000458:organization & administration*; D006801:Humans; D017146:Models, Organizational; D009722:Nurse Practitioners; D015403:Nursing Evaluation Research; D010348:Patient Care Team / Q000458:organization & administration*; D010351:Patient Discharge; D010865:Pilot Projects; D011203:Poverty; D015397:Program Evaluation; D016032:Randomized Controlled Trials as Topic; D012947:Social Work / Q000458:organization & administration