***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: CONTEXT Illness and hospitalization often trigger functional decline among older persons .  Home care services implemented for functional decline provide an opportunity to intervene to improve outcomes . OBJECTIVE To compare functional status and the likelihood of remaining at home for persons receiving restorative care vs usual home care .  DESIGN AND SETTING Intervention using prospect i ve individual matching conducted between November 1 , 1998 , and April 30 , 2000 . Six offices of a home care agency in Connecticut were used . One branch office served as the restorative care unit and the other 5 served as usual care offices . PARTICIPANTS Patients receiving home care through the restorative care office who were 65 years or older ; in receipt of Medicare-covered home care lasting at least 7 days ; with absence of severe cognitive impairment ; and not terminal , bedridden , or requiring total care were matched with patients from 1 of the usual care offices  . The matching factors included age , sex , race , baseline self-care function , cognitive status , whether hospitalization preceded the home care episode , and date of the home care episode . Of the 712 eligible restorative care patients , 691 ( 97 % ) were matched with a usual care patient . INTERVENTION Restorative care , provided by the home care agency nursing , therapy , and home health aide staff , was based on principles from geriatric medicine , nursing , rehabilitation , and goal attainment . MAIN OUTCOME MEASURES Remaining at home , functional status at completion of the home care episode , and duration and intensity of home care episode . RESULTS Compared with usual care , and after adjusting for baseline characteristics and other factors , restorative care was associated with a greater likelihood of remaining at home ( 82 % vs 71 % ; odds ratio [ OR ] , 1.99 ; 95 % confidence interval [ CI ] , 1.47 - 2.69 ) and a reduced likelihood of visiting an emergency department ( 10 % vs 20 % ; OR , 0.44 ; 95 % CI , 0.32 - 0.61 ) . Home care episodes were shorter ( mean [ SD ] , 24.8 [ 26.8 ] days vs 34.3 [ 44.2 ] days ; S = -17 821 ; P<.001 ) . Restorative care patients had better mean ( SD ) scores than usual care patients in self-care ( 11.0 [ 2.1 ] vs 10.7 [ 2.5 ] ; P = .07 after adjustment ) , home management ( 9.5 [ 2.9 ] vs 9.2 [ 3.0 ] ; P = .05 after adjustment ) , and mobility ( 3.3 [ 0.8 ] vs 3.2 [ 0.9 ] ; P = .02 after adjustment ) . CONCLUSIONS This trial suggests that reorganizing the structure and goals of home care can enhance health outcomes of older patients without increasing health care utilization STUDY QUESTION Did the  Medicare Alzheimer 's Disease Demonstration , with its goal of improving caregiver outcomes through case management and subsidized community services , affect the nursing home entry rate of treatments with dementia compared to controls ? DATA SOURCES Interviews conducted at baseline and six months thereafter . Measures include date of nursing home entry , client and caregiver health , and income . STUDY DESIGN The demonstration r and omly assigned voluntary applicants into treatment and control groups . Treatment group cases were eligible for case management and for an 80 percent discount on community care benefits , up to about $ 600 per month . DATA COLLECTION All cases received baseline and semi-annual assessment interviews for up to three years after enrollment . Analyses are among cases that remained in the demonstration for more than 30 days after enrollment ( n = 8,095 ) . PRINCIPAL FINDINGS The intervention of case management and subsidized community service had no effect on nursing home entry rates for treatments overall , compared to those of controls , and few effects on treatment subgroups , with the exception of one site where it may have increased nursing home entry rates . CONCLUSIONS Providing case management and subsidized community services with the goal of improving caregiver outcomes may have little effect on nursing home entry rates for people with dementia Objectives The aim was to evaluate the effects of integrated home care and discharge practice on the functional ability ( FA ) and health-related quality of life ( HRQoL ) of home care patients . Methods A cluster r and omised trial ( CRT ) with Finnish municipalities ( n=22 ) as the units of r and omisation . At baseline the sample included 669 patients aged 65 years or over . Data consisted of interviews ( at discharge , and at 3-week and 6-month follow-up ) , medical records and care registers . The intervention was a generic prototype of care/case management- practice ( IHCaD- practice ) that was tailored to municipalities needs . The aim of the intervention was to st and ardize practice s and make written agreements between hospitals and home care administrations , and also within home care and to name a care/case manager pair for each home care patient . The main outcomes were HRQoL — as measured by a combination of the Nottingham Health Profile ( NHP ) and the EQ-5D instrument for measuring health status— and also Activities of Daily Living ( ADL ) . All analyses were based on intention-to-treat . Results At baseline over half of the patient population perceived their FA and HRQoL as poor . At the 6-month follow-up there were no improvements in FA or in EQ-5D scores , and no differences between groups . In energy , sleep , and pain the NHP improved significantly in both groups at the 3-week and at 6-month follow-up with no differences between groups . In the 3-week follow-up , physical mobility was higher in the trial group . Conclusions Although the effects of the new practice did not improve the patients ' FA and HRQoL , except for physical mobility at the 3-week follow-up , the workers thought that the intervention worked in practice . The intervention st and ardised practice s and helped to integrate services . The intervention was focused on staff activities and through the changed activities also had an effect on patients . It takes many years to achieve permanent changes in every worker 's individual practice and it is also likely that changes in working practice s would be visible before effects on patients . The use of other outcome measures , such as the use of services , may be clearer in showing a positive impact of the intervention rather than FA or STUDY QUESTION Did the  Medicare Alzheimer 's Disease Demonstration with its case management and community service waivers affect the use of community-based long-term care services among people with dementia and their primary caregivers ? DATA SOURCES Baseline and periodic caregiver interviews . Measures include client and caregiver attributes and self-reported service use . STUDY DESIGN The demonstration r and omly assigned voluntary applicants into treatment and control groups . Treatment group cases were eligible for case management  and for up to $ 699 per month in community care benefits . The actual monthly entitlement varied among the eight demonstration communities due to regional cost and inflation adjustments over time . Analyses are for the year after enrollment . DATA COLLECTION Analyses are of cases surviving six months or more in the community after enrollment ( n = 5,209 ) . Cases received baseline and semi-annual assessment s. PRINCIPAL FINDINGS The intervention of case management and community service reimbursement had a strong , consistent , and positive effect on the likelihood of using home care ( including homemaker/chore services , personal care services , companion services ) and adult day care . Treatment group clients were at least twice as likely as control group clients to be using any of the four community-based services . A similar , but less pervasive effect was achieved with caregiver training and support group participation . Reimbursement provided by the demonstration 's Medicare waiver was generally not sufficient to exceed the level of control group service acquired through private payment . CONCLUSIONS Reimbursement levels within the demonstration may have enabled more individuals to purchase some services , but they were not sufficient to increase the average level of use over those in the control group . No consistent differences between demonstration models were found in service use likelihood or average use among users Abstract Objective : To evaluate the impact of a programme of integrated social and medical care among frail elderly people living in the community . Design : R and omised study with 1 year follow up . Setting : Town in northern Italy ( Rovereto ) . Subjects : 200 older people already receiving conventional community care services . Intervention : R and om allocation to an intervention group receiving integrated social and medical care and case management or to a control group receiving conventional care . Main outcome measures : Admission to an institution , use and costs of health services , variations in functional status . Results : Survival analysis showed that admission to hospital or nursing home in the intervention group occurred later and was less common than in controls ( hazard ratio 0.69 ; 95 % confidence interval 0.53 to 0.91 ) . Health services were used to the same extent , but control subjects received more frequent home visits by general practitioners . In the intervention group the estimated financial savings were in the order of £ 1125 ( $ 1800 ) per year of follow up . The intervention group had improved physical function ( activities of daily living score improved by 5.1 % v 13.0 % loss in controls ; P<0.001 ) . Decline of cognitive status ( measured by the short portable mental status question naire ) was also reduced ( 3.8 % v 9.4 % ; P<0.05 ) . Conclusion : Integrated social and medical care with case management programmes may provide a cost effective approach to reduce admission to institutions and functional decline in older people living in the community . Key messages Responsibility for management of care of elderly people living in the community is poorly defined Integration of medical and social services together with care management programmes would improve such care in the community In a comparison of this option with a traditional and fragmented model of community care the integrated care approach reduced admission to institutions and functional decline in frail elderly people living in the community and also reduced OBJECTIVE To examine how a new model of consumer-directed care changes the way that consumers with disabilities meet their personal care needs and , in turn , affects their well-being . STUDY SETTING Eligible Medicaid beneficiaries in Arkansas , Florida , and New Jersey volunteered to participate in the demonstration and were r and omly assigned to receive an allowance and direct their own Medicaid supportive services as Cash and Counseling consumers ( the treatment group ) or to rely on Medicaid services as usual ( the control group ) . The demonstration included elderly and non-elderly adults in all three states and children in Florida . DATA SOURCES Telephone interviews administered 9 months after r and om assignment . METHODS Outcomes for the treatment and control group were compared , using regression analysis to control for consumers ' baseline characteristics . PRINCIPAL FINDINGS Treatment group members were more likely to receive paid care , had greater satisfaction with their care , and had fewer unmet needs than control group members in nearly every state and age group . However , among the elderly in Florida , Cash and Counseling had little effect on these outcomes because so few treatment group members actually received the allowance . Within each state and age group , consumers were not more susceptible to adverse health outcomes or injuries under Cash and Counseling . CONCLUSIONS Cash and Counseling substantially improves the lives of Medicaid beneficiaries of all ages if consumers actually receive the allowance that the program offers OBJECTIVES To compare the effects of nurse case management with usual care provided to community-dwelling frail older people in regard to quality of life , satisfaction with care , functional status , admission to hospital , length of hospital stay , and readmission to emergency department . DESIGN R and omized controlled trial . SETTING University hospital and two proximal community health centers . PARTICIPANTS 427 frail older people ( > or = 70 years of age and at risk for repeated hospital admissions ) discharged home from the emergency department . INTERVENTIONS EXPERIMENTAL Nurse case management , which consisted of coordination and provision of healthcare services by nurses , both in and out of hospital , for a 10-month period . CONTROL Usual care , which varied by healthcare provider and community health center . MEASUREMENTS Outcomes were assessed 10 months post-r and omization by telephone and /or home interview and by medical record review . Question naires included the SF-36 , CSQ-8 , and OARS . RESULTS No significant differences were found in quality of life , satisfaction with care , functional status , admission to hospital , or length of hospital stay . Nurse-case-managed older adults were readmitted to the emergency department significantly more often than their usual care counterparts . CONCLUSIONS Frail older people receiving nurse case management are more likely to use emergency health services without a concomitant increase in health benefits Context Dementia is an incurable chronic disease , but assistance to caregivers can reduce the severity of patients ' symptoms and delay institutionalization . Because this assistance requires provision of multiple health care and social services , patients and caregivers might benefit from a coordinated system of care . Contribution The investigators r and omly assigned patients with dementia and their caregivers to usual care or to a coordinated system of care . In the coordinated system , care managers regularly assessed patient and caregiver pairs and coordinated guideline -recommended provision of services by health care providers and community agencies using computerized information systems . The study found that pairs cared for in the coordinated system received higher- quality health care and more needed assistance than those who received usual care . Caution s The study focused on a relatively homogeneous population of white , well-educated , otherwise healthy , noninstitutionalized patients with health insurance . The findings might not apply to other population s. Implication s The quality of care for patients with dementia and their caregivers can be improved with a model of care in which services provided by the health system and community agencies are coordinated by a care manager . The Editors Dementia has enormous health and financial consequences for affected individuals , their family caregivers , and society ( 15 ) . Although most dementia is currently neither preventable nor reversible , existing practice guidelines reflect evidence from r and omized , controlled trials that caregiver assistance 
    Output:
    
Evidence from r and omized controlled trials showed that case management improves function and appropriate use of medications , increases use of community services and reduces nursing home admission .
Evidence , mostly from non-r and omized trials , showed that integrated care increases service use ; r and omized trials reported that integrated care does not improve clinical outcomes .
The lowest quality evidence was for consumer directed care which appears to increase satisfaction with care and community service use but has little effect on clinical outcomes .
Conclusions The outcomes of each model of care differ and correspond to the model 's focus .
Combining key elements of all three models may maximize outcomes