Description:
C10598: Guided Care – comprehensive care for people with complex health-related needs and high healthcare costs
Unmet need
People who have chronic health-related problems that require complex health care are often served sub-optimally by fee-for-service healthcare systems. Their care may be fragmented, uncoordinated, non-aligned with their values and priorities, and unresponsive to the needs of their family caregivers. It is always very expensive. Fortunately, new value-based payment models now offer financial incentives for healthcare systems to provide this population with care that is comprehensive, coordinated, proactive and aligned with patients’ and families’ values.
Technology overview
In alignment with these emerging incentives, “Guided Care” now offers a novel solution for providing high-value healthcare for people with complex needs – and for their families.
· In Guided Care, a specially certified registered nurse, who is based in a primary care practice, partners with the patient’s other providers in delivering eight services to 75-100 chronically ill patients. Following a comprehensive in-home assessment and planning process, the Guided Care Nurse monitors each patient monthly, guides the patient’s self-management, smooths the patient’s transitions between sites of care, coordinates the efforts of all of the patient’s providers, facilitates the patient’s access to community services and supports the patient’s family caregivers.
· A Guided Care license provides licensees with:
o Permission to use the Guided Care model and name
o The “Health History Questionnaire” that guides the in-home assessment
o A template for the “Preliminary Care Guide” (the Guided Care Nurse’s initial draft plan of care that results from the in-home assessment)
o A template for the “Care Guide” (the final plan of care that integrates input from the Guided Care Nurse, the physician, the patient and the caregiver)
o A template for the “Action Plan” (the patient-friendly version of the “Care Guide” that reminds the patient of personalized self-management tasks that will optimize health and function).
· Implementation of Guided Care in primary care practices is facilitated by:
o A detailed implementation manual
o An online 40-hour course provided by the Institute for Johns Hopkins Nursing to prepare RNs to become Guided Care Nurses
o A patient information booklet.
· A cluster-randomized controlled trial (n=904) showed that Guided Care provides high-value care by improving the quality of care and reducing complex (expensive) patients’ overall healthcare costs. It also improves physicians’ satisfaction and reduces the strain felt by family caregivers.
Future use
Guided Care is a valuable solution for healthcare systems that wish to succeed as they make the transition from fee-for-service to value-based models of payment for healthcare.
Publications
Boult C, Leff B, Boyd CM, Wolff JL, Marsteller JA, Frick KD, Wegener S, Reider L, Frey K, Mroz TM, Karm L, Scharfstein DO. A matched-pair cluster-randomized trial of Guided Care for high-risk older patients. J Gen Intern Med 2013;28(5):612-621.
Marsteller JA, Hsu YJ, Wen M, Wolff J, Frick K, Reider L, Scharfstein D, Boyd C, Leff B, Schwartz L, Karm L, Boult C. Effects of Guided Care on providers' satisfaction with care: A three-year matched-pair cluster-randomized trial. Popul Health Manag 2013,16(5):317-25.
Boult C, Reider L, Leff B, Frick KD, Boyd CM, Wolff JL, Frey K, Karm L, Wegener ST, Mroz T, Scharfstein DO. The effect of Guided Care teams on the use of health services: results from a cluster-randomized trial. Arch Intern Med 2011;171(5):460-466.
Marsteller J, Hsu Y-J, Reider L, Frey K, Wolff J, Boyd C, Leff B, Karm L, Scharfstein D, Boult C. Physician satisfaction with chronic care: a randomized trial of Guided Care. Ann Fam Med 2010;8:305-315.
Boyd CM, Reider L, Frey K, Scharfstein D, Leff B, Wolff J, Groves C, Karm L, Wegener S, Marsteller J. Boult C. The effects of Guided Care on the perceived quality of health care for multi-morbid older persons: 18-month outcomes from a cluster-randomized controlled trial. J Gen Intern Med 2010;25(3):235-242.
Wolff JL, Giovannetti ER, Boyd CM, Reider L, Palmer S, Scharfstein D, Marsteller J, Wegener S, Frey K, Leff B, Boult C. Effects of Guided Care on family caregivers. Gerontologist 2010;50(4):459-470.
Leff B, Reider L, Frick KD, Scharfstein D, Boyd CM, Frey K, Karm L, Boult C. Guided Care and the cost of complex health care. Am J Manag Care 2009;15(8):555-559.
Wolff JL, Rand-Giovannetti E, Palmer S, Wegener S, Reider L, Frey K, Boult C. Caregiving and chronic care: the Guided Care program for families and friends. J Gerontol Med Sci 2009; 64A(7):785-791.
Boyd CM, Shadmi E, Conwell LJ, Griswold M, Leff B, Brager R, Sylvia M, Boult C. A pilot test of the effect of Guided Care on the quality of primary care experiences for multi-morbid older adults. J Gen Intern Med. 2008;23(5):536-42.
Boult C, Reider L, Frey K, Leff B, Boyd C, Wegener S, Marsteller J, Karm L, Scharfstein D. Early effects of Guided Care on the quality of health care for multimorbid older persons: a cluster-randomized controlled trial. J Gerontol Med Sci 2008;63A(3):321-27.
Sylvia ML, Griswold M, Dunbar L, Park M, Boult C. Guided Care: cost and utilization outcomes in a pilot study. Disease Manag 2008;11(1):29-36.
Boyd CM, Boult C, Shadmi E, Leff B, Brager R, Dunbar L, Wolff JL. Guided Care for multi-morbid older adults. Gerontologist 2007;47(5):697-704.
