Integrated county medical consortium nursing management for older adults with disabilities: a retrospective cohort study

To assess the efficacy of integrated County Medical Consortium (CMC) nursing management versus conventional care for older adults with disabilities. A retrospective cohort study analyzed records of 131 older adults (≥ 65 years, Barthel Index ≤ 60). Participants were non-randomly allocated according to care-pathway preferences to an innovative nursing group (n = 67, a 6-month CMC program including coordinated home visits, caregiver training, multidisciplinary follow-up, a consultation hotline, and information sharing) or a conventional group (n = 64, routine hospital care). Primary outcomes included Activities of Daily Living (ADL) and SF-36 quality of life (QoL) scores at baseline, 1, 3, and 6 months; secondary outcomes covered healthcare utilization, complications, caregiver burden, and exploratory patient and family caregiver satisfaction. Longitudinal outcomes were analyzed using linear mixed-effects models; healthcare utilization outcomes were analyzed using covariate-adjusted gamma or negative binomial regression, as appropriate. Baseline characteristics were comparable between groups. The innovative group showed higher ADL scores from month 1, with significant differences at month 3 (P = 0.015) and month 6 (P = 0.004). SF-36 scores were significantly higher in the innovative group at months 3 (P = 0.032) and 6 (P < 0.001). In covariate-adjusted analyses, the innovative group had a shorter length of stay and fewer ED and outpatient visits (all P ≤ 0.035). Complication rates and caregiver burden were lower, whereas the readmission rate was numerically lower but did not reach statistical significance (P = 0.059). Exploratory patient and family caregiver satisfaction scores were higher. Integrated CMC nursing management was associated with improved functional independence, QoL, and overall healthcare outcomes among older adults with disabilities, supporting prospective evaluation of the model in other settings. Many older adults in China struggle with daily activities like bathing, dressing, and eating. They often receive care from different places that do not communicate with each other. This can lead to confusion, repeated hospital visits, and poor health outcomes. Family members caring for these older adults often feel overwhelmed. We tested a new way of providing care. Nurses from county hospitals, township clinics, and village health stations worked together as one team. They followed 67 older adults with disabilities for six months, coordinating their care from hospital to home. We compared their outcomes with 64 similar patients who received usual hospital care. Older adults in the coordinated care group showed meaningful improvements. They became more independent in daily activities. They reported feeling better overall. They spent fewer days in hospital and had fewer emergencies. They also had fewer health problems like infections and falls. Their family caregivers felt less burdened. Both patients and families were happier with the care received. These findings matter for patients, families, and healthcare systems. Coordinated nursing care helps older adults maintain independence and stay healthier at home. It reduces pressure on hospitals and eases stress on family caregivers. For China’s rapidly aging population, this approach offers a practical solution that can be adopted in other regions. Policymakers should consider expanding this model as part of ongoing healthcare reforms.