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Managing Elders With Comorbidities

Schraeder, Cheryl PhD, RN, FAAN; Dworak, Donna MS, RN; Stoll, John F. MD, FACP, CPE; Kucera, Chris BFAID; Waldschmidt, Valerie AA; Dworak, Melissa Pollard BA

Journal of Ambulatory Care Management: July-September 2005 - Volume 28 - Issue 3 - p 201–209

Carle's Medicare Coordinated Care Demonstration care/disease management interventional components, based on the chronic care model, are described for elderly patients in 13 counties in Illinois. Patients enrolled in the program are diagnosed with chronic obstructive pulmonary disease, coronary artery disease, diabetes, atrial fibrillation, or congestive heart failure. Primary care teams are made up of a primary care physician, an advanced practice nurse, a nurse case manager, and a case assistant. The patient/family is the cornerstone of the intervention, which is evaluated using a prospective, longitudinal randomized treatment-control design.

Health Systems Research Center, Carle Foundation Hospital (Dr Schraeder and Mss D. Dworak, Waldschmidt, M. P. Dworak, and Kucera), and Primary Care and Pediatric Subspecialties, Carle Clinic Association (Dr Stoll), Urbana, Illinois.

Corresponding author: Cheryl Schraeder, PhD, RN, FAAN, Health Systems Research Center, Carle Foundation Hospital, 307 E Oak St, PO Box 718, Mahomet, IL 61853 (e-mail:

© 2005 Lippincott Williams & Wilkins, Inc.