Effectiveness of a community care management program for multimorbid elderly patients with heart failure in the Veneto Region

Published: January 7, 2019
Category: Bibliography
Authors: Cristina Basso, Elena Schievano, Francesco Avossa, Giulia Capodaglio, Maria Chiara Corti; PhD, Matilde Dotto, Silvia Netti Tiozzo, Ugo Fedeli
Countries: Italy
Language: null
Types: Care coordination, Care Management, Population Health
Settings: Government, Health Plan, Hospital, PCP, Specialist



The rapidly growing population of elderly subjects with multimorbidity is at risk of receiving fragmented and uncoordinated care, and have frequent hospitalizations and emergency room (ER) visits.


The study aims to describe the impact of a care management program (CMP) developed in the Veneto region (Northeastern Italy) for patients affected by chronic heart failure (CHF) and multimorbidity.


The CMP was provided to 330 patients > 65 years suffering from CHF and multimorbidity. They were compared to a propensity score matched reference group who received usual care. The intervention was provided by care manager nurses and General Practitioners working in the community. The quality of care from the patients’ perspective was assessed by means of the Patient Assessment of Chronic Illness Care (PACIC). The effectiveness of the CMP has been evaluated comparing time changes in hospital admissions in the medical area and ER visits between the intervention and the reference group.


The median PACIC overall score was 4 out of 5. The intervention group showed a reduction over time by 39% in hospitalization rates and by 33% in ER visits. The recourse to hospital care and ER did not change in the reference group.


The current results indicate that a CMP can reduce Emergency Room visits and hospital admissions for elderly patients with CHF and multimorbidity.


The CMP by emphasizing prevention, self-management, continuity and coordination of care, is beneficial among older community-dwelling multimorbid persons as compared to usual care.

Care management,Multimorbidity,Chronic heart failure,Hospitalization,Emergency room visits

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