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Linking Clinical Practice and Community Resources:The Guided Care Model

Slide Presentation from the AHRQ 2009 Annual Conference

On September 14, 2009, Chad Boult made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (626 KB) (Plugin Software Help).

Slide 1

Linking Clinical Practice and Community Resources:<br /><br />The Guided Care Model. Text Description is below the image.

Linking Clinical Practice and
Community Resources:

The Guided Care Model

Chad Boult, MD, MPH, MBA
Professor of Public Health, Medicine and Nursing
Johns Hopkins University


AHRQ 2009 Annual Conference
September 14, 2009

Slide 2

Ms. Marian Chen. Text Description is below the image.

Ms. Marian Chen

  • 79 year old widow
  • Retired teacher, lives alone
  • Income: SS, pension and Medicare
  • Daughter, lives 10 miles away with three teenagers
  • Five chronic conditions
  • Three physicians
  • Eight medications

 

Slide 3

In 2009, Mrs. Chen has had... Text Description is below the image.

In 2009, Mrs. Chen has had...

 

Slide 4

. Text Description is below the image.
  • Mrs. Chen
    • Confused by care, meds
    • Poor quality of life
    • High out-of-pocket costs
  • Daughter
    • Stressed out
    • Reduced work to half-time
    • Considering nursing homes

Medicare paid $42,400 to providers for her care
(not including medications)

 

Slide 5

Chronic care is:. Text Description is below the image.

Chronic care is:

  • Fragmented
  • Discontinuous
  • Difficult to access
  • Inefficient
  • Unsafe
  • Expensive

 

Slide 6

. Text Description is below the image.

Source: Medicare 5% Sample, 2001
The ΒΌ of Beneficiaries Who Have 4+ Chronic Conditions Account for 80% of Medicare Spending

 

Slide 7

Goals. Text Description is below the image.

Goals

    • Create a model that improves quality of care and reduces costs
    • Make the model diffusable throughout the United States

 

Slide 8

The Guided Care Model. Text Description is below the image.

The Guided Care Model

  • Specially trained RNs based in primary physicians' offices
  • GCNs collaborate with physicians in caring for 50-60 high-risk older patients with chronic conditions and complex health care needs

 

Slide 9

Nurse/physician team. Text Description is below the image.

Nurse/physician team

  • Assesses needs and preferences
  • Creates an evidence-based "care guide" and a patient-friendly "action plan"
  • Monitors the patient proactively
  • Supports chronic disease self-management
  • Smoothes transitions between care sites
  • Communicates with providers in EDs, hospitals, specialty clinics, rehab facilities, home care agencies, hospice programs, and social service agencies in the community
  • Educates and supports caregivers
  • Facilitates access to community services

 

Slide 10

Linking with Community Resources. Text Description is below the image.

Linking with Community Resources

  • Data base of local community resources
  • Facilitate access to appropriate services
    • Empowerment
    • Paternalism
  • Meals on Wheels, senior centers, AAA, transportation programs, adult day care, CDSMP, social workers, pharmacists
  • GCN support groups? community support groups

 

Slide 11

Image about improved outcomes. Text Description is below the image.

[Image about improved outcomes]

 

Slide 12

Who is Eligible? Text Description is below the image.

Who is Eligible?



All
Patients
Age 65+


25%
High-Risk
75%
Low-Risk
Review previous year's claims data with HCC software

 

Slide 13

Randomized Trial. Text Description is below the image.

Randomized Trial

  • High-risk older patients (n=904) of 49 community-based primary care physicians practicing in 14 teams
  • Physician/patient teams randomly assigned to receive Guided Care or "usual" care
  • Outcomes measured at 8, 20 and 32 months

 

Slide 14

Baseline Characteristics. Text Description is below the image.

Baseline Characteristics

 

Slide 15

Effects on Physician Satisfaction. Text Description is below the image.

Effects on Physician Satisfaction

 

Slide 16

. Text Description is below the image.

Very Satisfied
Very Dissatisfied
Satisfaction Items
1= Familiarity with patients
2= Stability of patient relationships
3= Comm. w/ patients; Availability of clinical info; continuity of care for patients
4= Efficiency of office visits; access to evidence based guidelines
5= Monitoring patients; communicating w/ caregivers; efficiency of primary care team
6= Coordinating care; referring to community resources; educating caregivers
7= Motivating patients for self management
Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Dissatisfied

 

Slide 17

Effects on Quality of Care. Text Description is below the image.

Effects on Quality of Care

* Adjusted for baseline socio-demographics, health, function, PACIC scores, site

 

Slide 18

Effects on Caregiver Strain. Text Description is below the image.

Effects on Caregiver Strain

 

Slide 19

Annual Costs of Guided Care. Text Description is below the image.

Annual Costs of Guided Care

 

Slide 20

Effects on Costs of Care<br />(per caseload, 55 patients). Text Description is below the image.

Effects on Costs of Care
(per caseload, 55 patients)

 

Slide 21

Early Results. Text Description is below the image.

Early Results

  • Guided Care improves the quality of chronic care.
  • Guided Care reduces net expenditures for health care.
  • Guided Care is easy to implement and popular with physicians, nurses, patients and caregivers.

 

Slide 22

Future Directions. Text Description is below the image.

Future Directions

  • National pilot test involving Guided Care medical homes
  • Technical assistance
    • Book
    • Online course and certificate for nurses
    • Online course for physicians
    • Guidance in selecting HIT
    • Learning collaboratives and communities
    • Consultation

 

Slide 23

Grant Support. Text Description is below the image.

Grant Support

  • Agency for Healthcare Research and Quality
  • National Institute on Aging
  • John A. Hartford Foundation
  • Jacob and Valeria Langeloth Foundation

 

Slide 24

Publications. Text Description is below the image.

Publications

  • Boyd C et al. Gerontologist Nov 2007
  • Sylvia M et al. Dis Manag Feb 2008
  • Boyd C et al. J Gen Intern Med Feb 2008
  • Boult C et al. J Gerontology Mar 2008
  • Wolff et al. J Gerontology June 2009
  • Leff B et al. Am J Managed Care August 2009
  • "Guided Care: a New Nurse-Physician Partnership for Chronic Care." Springer Publishing Co. 2009
  • (www.springerpub.com/guidedcare)
  • wwwguidedcare.org

 

Current as of December 2009

Internet Citation:

Linking Clinical Practice and Community Resources:The Guided Care Model. Slide Presentation from the AHRQ 2009 Annual Conference (Text Version). December 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/annualconf09/boult.htm

 
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