Problem Addressed

• Many older adults with multiple, costly chronic conditions: Almost three-fourths of individuals aged 65 years and older have at least one chronic illness, while about one-half have at least two chronic illnesses.¹ More than 92 percent of Medicare spending in 2002 was incurred by beneficiaries with three or more chronic conditions.² As baby boomers age, the number of people with one or more chronic conditions will increase.³
• Fragmented care that reduces effectiveness: More than one-half of patients with serious chronic conditions receive treatment from three or more different physicians.⁴ One study found that care fragmentation across physicians and care sites contributed to an increased likelihood of hospitalization for seniors with chronic illnesses, even when alternative sites are available.⁵

Description of the Innovative Activity

• Identifying at-risk patients who can benefit from the program: Eligible patients are aged 65 years and older; have multiple, complex conditions; and are expected, in the absence of any intervention, to have high health expenditures in the near future. These patients are identified through a review of 12 months of health insurance claims and use of a predictive model (Medicare's hierarchical condition category predictive model⁶) to identify the 20 to 25 percent of older patients who have the highest predicted need for complex health care in the near future.
• Specially trained nurses placed in primary care practices: Specially trained registered nurses serve as Guided Care Nurses, working onsite at primary care practices. Each Guided Care Nurse coordinates care for a caseload of 50 to 60 older patients who have several chronic conditions.
• Ongoing care coordination: Guided Care Nurses work with PCPs, specialists, caregivers, and community organizations to coordinate and improve patient care across providers and settings. Eight clinical processes are provided:
  • Comprehensive assessment: The Guided Care Nurse performs an initial assessment of the patient's medical, functional, cognitive, affective, psychosocial, nutritional, and environmental status during a home visit, and asks the patient about his/her priorities for optimizing health and quality of life.
  • Evidence-based care planning: The Guided Care Nurse and the PCP work collaboratively with the patient and caregiver to develop an individualized Care Guide and a patient-friendly Action Plan.
  • Promoting patient self-management: Based on each patient's Action Plan, the Guided Care Nurse promotes and reinforces self-management skills, promotes the patient's confidence in managing his/her chronic conditions, and encourages each patient to take personal responsibility for his/her health. The Guided Care Nurse also refers the patient to local chronic disease self-management courses, where available.
  • Monthly monitoring of the patient's conditions: The Guided Care Nurse monitors the patient at least monthly by telephone to detect and address emerging problems promptly; the nurse discusses problems with the PCP and takes appropriate action.
  • Coordinating the efforts of all health care providers: The Guided Care Nurse coordinates the efforts of all health care professionals who treat Guided Care patients across health settings.
  • Smoothing transitions between sites of care: The Guided Care Nurse smooths the patient's path between all sites and providers of care by sharing the patient's Care Guide with providers, monitoring patients in the hospital, preparing patients for discharge, conducting a home visit on the patient's return home, and keeping the PCP informed of the patient's status.
  • Caregiver education and support: For the family or other unpaid caregivers, the Guided Care Nurse offers individual assistance, including an in-person assessment and ad-hoc telephone consultation.
  • Facilitating access to community resources: The Guided Care Nurse facilitates patients' and caregivers' access to community-based services for transportation, meals, and adult day care centers, etc., and assists them in accessing these resources efficiently.
• Use of EHR: Guided Care Nurses access a secure Web-based EHR that was specially designed for the program. The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions. Guided Care Nurses use the EHR to document care; review medications and test data; generate the Care Guide and Action Plan; and document contacts with patients, families, and health care providers.

References/Related Articles

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Results

A multiyear, cluster-randomized controlled trial (RCT) conducted at eight sites (including more than 900 patients, 300 family caregivers, and 49 PCPs) in the Baltimore-Washington, D.C. area revealed that Guided Care improves patient and caregiver perceptions of quality, produces high satisfaction among physicians, and may significantly reduce utilization and cost.

• Higher quality as perceived by patients and family caregivers: After 18 months, Guided Care patients were twice as likely as usual care patients to rate the quality of their care highly.⁷ Caregivers of Guided Care patients reported that the quality of chronic illness care received by their loved one to be significantly higher than usual caregivers.^8,9
• May lower costs and utilization: After 20 months, Guided Care patients experienced, on average, 30 percent fewer home health care episodes, 21 percent fewer hospital readmissions, 16 percent fewer skilled nursing facility days, and 8 percent fewer skilled nursing facility admissions (only the reduction in home health care episodes was statistically significant). Guided Care produced even larger reductions in a subset of patients who received their primary care from one well-managed health system (Kaiser Permanente).¹⁰
• Less work-related impact on family caregivers: After 18 months, family caregivers employed in addition to their caregiving role also reported increased work productivity, low absenteeism, and a decline in presenteeism.^8,9
• Higher physician and nurse satisfaction: Physicians who practiced Guided Care for 1 year rated their satisfaction with patient/family communication and their knowledge of their chronically ill patients' clinical conditions significantly higher than did their peers in the control group.¹¹ Guided Care Nurses reported a high regard for most aspects of their jobs, consistently expressing high satisfaction with work hour flexibility and the model of care they provide.¹²

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Nurse training: The Guided Care program team developed a course to teach registered nurses the skills needed to practice Guided Care. The 6-week, 40-hour Web-based curriculum covers chronic disease management, patient preferences, case management, geriatric assessment and care planning, transitional care, information technology, motivational interviewing and patient education, evidence-based guidelines, ethno-geriatrics, community resources, communication with physicians, and insurance benefits.
• Recruitment of Guided Care Nurse candidates: Job advertisements were placed by the two partner health care organizations, drawing many applications; successful candidates had to have completed the training course described above.
• Integration into primary care practices: Guided Care Nurses were integrated into the primary care practices over a 3- to 5-month period; the goal was to enable them to become effective members of the practice team and to educate practice staff about the Guided Care Nurse role. Once settled into the primary care clinics, the Guided Care Nurses spent time working with the PCPs and office staff to build a caseload of 50 to 60 patients. No training was required for the PCPs or office staff.
• Coordination of a chronic disease self-management course: Program leaders worked with Stanford University to offer a chronic disease self-management course for Guided Care patients. (Many states have implemented and are now offering this chronic disease self-management course to residents through funding from the U.S. Administration on Aging.)
• Development of caregiver support: Program leaders developed a tool to evaluate caregivers and a set of information for Guided Care Nurses to provide to caregivers of Guided Care patients.
• Community resources assessment: Each Guided Care Nurse developed a list of community resources for patients and caregivers. In addition, Guided Care Nurses visited their local Area Agencies on Aging to familiarize themselves with resources available within the local community.

Resources Used and Skills Needed

• Staffing: The ideal Guided Care Nurse candidate is a licensed registered nurse with at least 3 years of home care, case management, community health, and/or equivalent gerontologic nursing experience. As noted, each nurse handles between 50 and 60 patients.
• Costs: Each Guided Care Nurse costs about $96,000 annually to support, including salary, benefits, office space, and expenses (e.g., computer, cell phone, travel). Additional costs include training and EHR-related expenses. Physician practices with an EHR could build program-specific elements into their existing systems. Tuition for the online Guided Care Nurse Course and Certificate cost $1,900 per learner. Current members of the National Gerontological Nursing Association and the Case Management Society of America are eligible for discounted tuition of $1,500. Group and other professional organization discounts are available. Send an e-mail to guidedcare@son.jhmi.edu for more information about all discounts and for additional course information.

Funding Sources

Tools and Other Resources

• EHR functions
• Overview of chronic disease self-management programs
• Outline of the Guided Care Nurse curriculum
• Guided Care Nurse job description and recruitment posting

Getting Started with This Innovation

• Identify older patients who are most likely to benefit: Maximizing the program's value requires accurate identification of individuals with multiple comorbidities and complex health care needs. Use of predictive models such as Medicare's hierarchical condition category can accomplish this task.
• Guided Care Nurse recruitment, training, and practice: Nurses from a wide variety of backgrounds can provide Guided Care, although training about the elements of Guided Care is essential. Daily teamwork between the primary care providers and the Guided Care Nurse is essential.
• Ensure adequate caseload: The caseload needed to support a Guided Care Nurse within the clinic is about 50 to 60 older patients with multiple chronic conditions. Most PCPs (including general internists and family physicians) who provide care to 300 or more older individuals have at least 50 to 60 patients who could benefit from the services of a Guided Care Nurse.
• Consider sharing nurses across sites: Although the Guided Care studies are based on one nurse at each site, nurses could potentially be shared across two or more practices.
• Allow for appropriate startup time: Three to 5 months should be allowed for Guided Care Nurses to become integrated into the primary care practice and build up their caseload of patients and caregivers. Integration into practice works best when the practice team is clear about the role of the Guided Care Nurse, and they recognize the Guided Care Nurse as a team member.
• Provide office space: The practice must provide office space for the Guided Care Nurse that allows the nurse easy access to the physicians to facilitate communication.
• Provide Internet connection and laptop: Guided Care Nurses should be provided with a laptop and an Internet connection that allows updated patient information to be entered into the EHR. Practices with EHRs in place can build program-specific functionality into their existing systems.
• Set up mechanism to notify nurses of hospitalizations: Guided Care Nurses need to be notified when one of their patients is hospitalized; notification can come from the practice or through a partnership with hospitals in the area.

Sustaining This Innovation

• Work with payers to support reimbursement mechanisms: An ongoing funding stream is critical to the sustainability of this type of program. At present, program leaders are building a business case to support reimbursement of program services by managed care organizations and Medicare. PCPs can use the Guided Care model to transform into patient-centered medical homes or Accountable Care Organizations (ACOs) to improve the care of patients with multiple chronic conditions. The Affordable Care Act of 2010¹³ may present new opportunities for use of the Guided Care model.
• Obtain periodic feedback from physicians, nurses, and patients: Sustained, successful operation of this program depends on obtaining periodic feedback from physicians, nurses, and patients and adjusting interactions accordingly.

Additional Considerations and Lessons

The Guided Care model has received widespread recognition. Selected honors are listed below (for a complete listing, see http://www.guidedcare.org/news-awards.asp):

• 2008 Archstone Foundation Award for Excellence in Program Innovation, from the American Public Health Association
• 2009 Medical Economics Award for Innovation in Practice Improvement, cosponsored by the Society of Teachers of Family Medicine, the American Academy of Family Physicians, and Medical Economics magazine
• Finalist, 2010 Getting Research into Practice Award, from the British Medical Journal Group
• 2010 Case In Point Platinum Award for Case Management Provider Program (won by the Guided Care Program at Kaiser Permanente) and 2011 Sliver Crown Award (won by Guided Care Program at Johns Hopkins Healthcare), awarded by Dorland Health

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