Aging Clinical and Experimental Research

, Volume 31, Issue 2, pp 241–247 | Cite as

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

  • Silvia Netti TiozzoEmail author
  • Cristina Basso
  • Giulia Capodaglio
  • Elena Schievano
  • Matilde Dotto
  • Francesco Avossa
  • Ugo Fedeli
  • Maria Chiara Corti
Original Article



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 




Compliance with ethical standards

Conflict of interest

All authors declare that they have no conflicts of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from patients enrolled in the intervention group.


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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Epidemiological Service of the Veneto RegionAzienda ZeroPaduaItaly

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