Improving care for older adults with chronic conditions
Official title: Evaluation of CMS Transitional Care and Chronic Care Management Services: Bridging the Gap and Maximizing Potential
Funded at Hebrew Rehabilitation Center for Aged · NIH-11170827 · Data updated 2026-11-12
This study is looking at how helpful Transitional Care Management and Chronic Care Management services are for older adults, especially those with frailty and dementia, to see if these services can help them stay healthier, live longer, and spend more time at home instead of in the hospital.
Quick facts
| Grant type | NIH-funded research |
|---|---|
| Study type | NIH-funded research |
| Funding institution | Hebrew Rehabilitation Center for Aged NIH-funded |
| Lab location | 1 site (Boston, United States) |
| Project start | September 26, 2024 |
| Project end | August 31, 2025 |
| Funding year | 2024 |
| Award (this year) | $794,956 |
| NIH project number | 1R56AG084578-01A1 |
| Project ID | NIH-11170827 on NIH RePORTER |
Who could benefit from this research
✓Could help
Ideal candidates for this research are older adults, particularly those with frailty, dementia, and challenging social determinants of health.
✕Less likely to help
Patients who are younger or do not have chronic conditions may not receive benefit from this research.
What this research studies
This research evaluates the effectiveness of Transitional Care Management (TCM) and Chronic Care Management (CCM) services aimed at enhancing the health outcomes of older adults. It focuses on addressing the medical and psychosocial needs of patients, particularly those with frailty and dementia, by improving care coordination and increasing the adoption of these services. The study will analyze how these services can lead to more days spent at home, better survival rates, and reduced Medicare costs compared to usual care. A team of experts will utilize various methodologies to assess the impact of these services on older adults' health.
Why it matters
Potential benefit: If successful, this research could lead to improved health outcomes and quality of life for older adults with chronic conditions.
How similar studies have gone: Previous research has shown that similar patient-centered care approaches can lead to significant improvements in health outcomes for older adults.
Where this research is happening
-
Hebrew Rehabilitation Center for Aged
Boston, United States Active
Researchers
- Principal investigator: Kim, Dae Hyun — Hebrew Rehabilitation Center for Aged
- Study coordinator: Kim, Dae Hyun
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About this research
- This is an active NIH-funded research project — typically early-stage science, not a clinical trial accepting patient enrollment.
- Some NIH-funded labs run parallel clinical studies or seek volunteers for related work. To check, contact the principal investigator or institution listed above.
- For full project details, budget, and progress reports, visit the official NIH RePORTER page.