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  1. Wright, Kathy MSN, RN, APN, BC
  2. Hazelett, Susan RN, MS
  3. Jarjoura, David PhD
  4. Allen, Kyle DO


Interdisciplinary care management that fully integrates medical and social care is advocated for optimal care of patients with many types of chronic illnesses, yet the effectiveness of this care model has been insufficiently tested using randomized controlled trials. This article presents the results of a pilot care management program and a description of a larger randomized controlled trial modeled after the pilot program (the After Discharge Care Management of Low-Income Frail Elderly [AD-LIFE] trial). It compares an integrated medical and social care management model (intervention group) with a purely social model (control group) involving low-income elderly patients with chronic conditions and functional impairment at high risk for rehospitalization or nursing home placement. A case study of a patient participant in the AD-LIFE study is presented. The case illustrates the positive effects of the intervention on biopsychosocial outcomes.