From 1995 to 1998, staff at the Council on Aging of the Cincinnati Area developed a project to enhance care for the frail elderly by linking acute and long-term care services and improving communication and coordination among providers.

It was designed to build on opportunities created by the Elderly Services Program, created after voter approval of a property tax levy that generated $12.6 million annually to provide comprehensive in-home care and community services to disabled older citizens.

The project was part of the Robert Wood Johnson Foundation (RWJF) Building Health Systems for People with Chronic Illnesses program.

Key Results

• The initiative created a geriatric team, including a clinical nurse liaison and a geriatrician, to coordinate medical management of this high-risk group.
• Researchers examined the use of an advanced computer information system to link primary care physicians with home providers and the area's hospitals.

Key Findings

• The evaluation showed no major differences between the intervention and control groups, suggesting that there were not sufficient financial or regulatory incentives for providers to alter service patterns.

Funding
RWJF funded this project through a grant of $438,940.