Effects on well-being, quality of care and costs of the combined Chronic Care Model and a population health management model: Embrace

Abstract

Background Embrace is a new care model for elderly people living in the community, which combines the Kaiser Permanente (KP) triangle with the Chronic Care Model (CCM). The KP triangle is a population health management model that divides patients with chronic conditions into three distinct groups based on their degree of need. Embrace encompasses an Elderly Care Team per General practitioner (GP), an Electronic Elderly Record System, decision support instruments, and a self-management support and prevention program. Its intensity of care and support varies per profile: Robust, Frail and Complex needs. Methods We assessed the effectiveness of Embrace concerning well-being and complexity of care needs of the elderly, quality of care, service use and costs with a Randomized Controlled Trial among elderly people (aged 75 years and older) living in the community. The intervention occurred from January 2012 to April 2013. Embrace was delivered by Elderly Care teams led by a GP and further consisted of an elderly care physician, a district nurse, and a social worker (both district nurse and social worker acting as case managers). Results In total1476 elderly people registered in 15 GP practices in the province of Groningen were included in the study and were stratified to the three Embrace profiles: 59% to the Robust profile, 16% to the Frail profile and 25% to the Complex needs profile. Next patients were randomized to the control group (n = 719) that received care-as-usual, or to the intervention group (n = 757) that received Embrace care and support. The results after one year of intervention will be presented. We expect improved well-being and decreased care needs for the elderly people, improved quality of care and decreased – or at leased stable – overall levels of service use and costs. Conclusions We succeeded to develop and to realize a promising new care model that includes all CCM key-elements in combination with a population health management model (KP-triangle). Effectiveness of this model was examined with a strong design. The follow-up period may be too short to demonstrate cost effectiveness because of the so-called ‘investment effect’. Therefore, the intervention period is prolonged in order to measure the real long-term effectiveness of Embrace.