Colorado PROFILES, The Colorado Clinical and Translational Sciences Institute (CCTSI)
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Patient-Centered Care Management/Seniors/Multimorbidities

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Multimorbid chronic medical conditions present an increasing disease burden for older persons and place them at risk for poor health outcomes including decreased physical functioning and loss of independence. Current standard care that emphasizes management of individual diseases may not be sufficiently comprehensive for persons with multiple chronic conditions, diseases or disabilities. In addition, optimal care of chronic medical conditions depends heavily on self-care, and the elderly are at particular risk for experiencing barriers to the medical self-care process. We propose to investigate the medical care needs and processes of a geriatric population with the three chronic health conditions of osteoarthritis, diabetes and depression. These conditions were chosen based on their high prevalence, interactions of symptoms and treatment, need for self-management, and potential to illustrate that care management for persons with these conditions may be more than the sum of existing disease management strategies. We will identify characteristics of this study population that place them at risk for decreased physical functioning and poor health status though a telephone survey that assesses potential barriers to medical self-care (such as social isolation, overwhelming effects of one condition, and conflicting recommendations for different conditions), level of patient activation, health literacy and cognitive abilities. We will then supplement this information with a qualitative exploration of the medical care needs through a series of focus groups. Working in the clinical and research arenas of the Colorado Region of Kaiser Permanente; we will use this information to further revise a proposed care management process for seniors with multimorbidities that utilizes care managers to assess patients' individual care needs and access appropriate resources to meet these needs. Finally we will conduct a feasibility pilot intervention to test this revised process of care in preparation for a larger intervention trial. If shown to be effective for a population with the three conditions in our investigation, patient-centered care management strategies such as the one we propose may then be extrapolated to populations of older persons with different constellations of chronic medical conditions. Given the public health impact of the growing numbers of seniors with multiple medical problems; effective and efficient models of care delivery that improve health and quality of life outcomes for this population have the potential to make a substantial contribution to a major health priority in the United States today.
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