As people live longer, chronic illness care will consume an ever-larger part of a nation's financial resources. With the 'baby-boomer' generation reaching retirement age beginning in 2011, there will be an increased demand for chronic services/care in the population aged 65 years and older. Innovative approaches to quality care must be sought, while understanding the financial costs associated with the delivery of such care to the geriatric population. Elderly persons utilize more physical resources and it is important to identify early those beneficiaries who would benefit medically from intervention.Disease management is built on a model of integrated care, with each member of the healthcare team working together toward a common set of objectives. The ultimate goal is to keep the patient functioning well in an outpatient setting, thus avoiding the high debility and costs associated with hospitalization and institutionaliza-tion. Creating such a system requires a substantial investment in infrastructure. The concept of 'spending us5.00 to save us10.00' must be incorporated into the planning process. In chronically ill seniors there is a need for care as well as cure, which involves improving function and quality of life (QOL) for the frail elders by paying attention to the psychological and socioeconomic status in addition to the physical condition. Small gains in function can mean large gains in patients' QOL. Reducing the progression of functional decline among the physically frail who live at home is a goal. Home visits are a critical component of the total care delivered.Changing physician behavior to accept the tenets of disease management requires education in advance of launching such a program. There must be healthcare team buy-in for a program to achieve success. Personnel requirements include senior nurses, social workers, physical therapists and nutritionists, supported by a sophisticated information technology system. Components of an information technology system must allow for adequate data collection and subsequent generation of reports. Continuous quality improvement will occur only if such a system is in place.While the average chronologic age of the patient with end-stage renal disease (ESRD) is almost 62 years, the physiologic age is much older. Therefore, ESRD serves as a model for chronic illness that affects a geriatric population and the benefits achieved by a disease management approach to this chronic disease are noted.Disease management improved glycemic control in the ESRD patient with diabetes mellitus by establishing a protocol for frequency of measurement of glycosylated hemoglobin (HgbA_(1c)). For this population at risk, a decreased hospitalization rate for diabetic complications resulted from this initiative. Also, a vascular access initiative in the described ESRD disease management program resulted in an increase in the creation of arterio-venous fistulas and a decrease in the placement of tunneled-cuff catheters. Fistula creation was associated with less infections and access thrombosis compared with catheter use for access. QOL improved for these patients with ESRD because of decreased hospitalization rate for access-related issues. Significant cost savings were achieved because of fewer hospital admissions and a decrease in the number of bed days per year.The lessons learned from the ESRD model can help in developing future disease management programs for the geriatric population.
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