Chronic care clinics: A randomized controlled trial of a new model of primary care for frail older adults

OBJECTIVE: To determine whether a new model of primary care, Chronic Care C linics, can improve outcomes of common geriatric syndromes (urinary inconti nence, falls, depressive symptoms, high risk medications, functional impair ment) in frail older adults. DESIGN: Randomized controlled trial with 24 months of follow-up. Physician practices were randomized either to the Chronic Care Clinics intervention o r to usual care. SETTING: Nine primary care physician practices that comprise an ambulatory clinic in a large staff-model HMO in western Washington State. PARTICIPANTS: Those patients aged 65 and older in each practice with the hi ghest risk for being hospitalized or experiencing functional decline. INTERVENTION: Intervention practices (5 physicians, 96 patients) held half- day Chronic Care Clinics every 3 to 4 months. These clinics included an ext ended visit with the physician and nurse dedicated to planning chronic dise ase management; a pharmacist visit that emphasized reduction of polypharmac y and high-risk medications; and a patient self-management/support group. C ontrol practices (4 physicians, 73 patients) received usual care. MEASUREME NTS: Changes in self-reported urinary incontinence, frequency of falls, dep ressive symptoms, physical function, and satisfaction were analyzed using a n intention-to-treat analysis adjusted for baseline differences, covariates , and practice-level variation. Prescriptions for high-risk medications and cost/utilization data obtained from administrative data were similarly ana lyzed. RESULTS: After 24 months, no significant improvements in frequency of incon tinence, proportion with falls, depression scores, physical function scores , or prescriptions for high risk medications were demonstrated. Costs of me dical care including frequency of hospitalization, hospital days, emergency and ambulatory visits, and total costs of care were not significantly diff erent between intervention and control groups. A higher proportion of inter vention patients rated the overall quality of their medical care as excelle nt compared with control patients (40.0% vs 25.3%, P = .10). CONCLUSIONS: Although intervention patients expressed high levels of satisf action with Chronic Care Clinics, improved outcomes for selected geriatric syndromes were not demonstrated. These findings suggest the need for develo ping greater system-wide support for managing geriatric syndromes in primar y care and illustrate the challenges of conducting practice improvement res earch in a rapidly changing delivery system.