Disease management in the frail and elderly population: integration of physicians in the intervention.

Abstract

As financial, social, and quality-of-life challenges associated with chronic disease in the United States continue to proliferate, disease management (DM) has been identified as a viable and positive approach that serves all areas of impact. Using an "in-house" model, Physician Health Partners, LLC, designed, developed, and implemented a DM program for the frail and elderly population. Given the special needs of this population the typical DM intervention was modified to include elements of physician involvement. The Frail and Elderly Program, as the DM program is called, produced statistically significant improvements in functional, behavioral, and clinical status and health-related quality of life. This model can help result in program success with potential benefits for individuals, practices, communities, and all whose lives are touched, directly or indirectly, by chronic disease.