Unmet Need
There is a growing number of aging Americans living with multiple morbidities, which has placed immense financial burden on healthcare programs across the country (CMS, 2012). Under the current model, older adult patients seek general medical care from their primary care physician (PCP), and additionally visit specialists for specific chronic health conditions. In this care model, PCPs are overwhelmed with the responsibility of not only providing the best care but also coordinating care between various specialists. A simple mistake in this care coordination can have severe consequences (Wiley-Blackwell, 2011). Moreover, as patients grow frailer, they have more difficulty following physician recommendations, leading to complications, hospitalizations, and emergency department visits, further driving up healthcare costs (Hostetter, 2016) Having a dedicated, trained health professional to assist physicians in the care coordination of older patients with multiple comorbidities can greatly improve health outcomes and reduce spending. Therefore, there is a strong need to develop new health care models to address these issues.
Technology Overview
Johns Hopkins researchers previously created the Guided Care model to better manage care for the growing number of aging American with multiple chronic conditions. This model involves training a registered nurse to work with a physician on the coordination of care. The nurse performs a standardized comprehensive home assessment and then collaborates with the physician, patient, and caregiver to generate management plans. Researchers have now developed four standardized forms that can be utilized to better facilitate patient care under the Guided Care model: 1) Health History (structures collection of specific clinical data from medical records, patients, and caregiver), 2) Preliminary Care Guide (working document by the nurse and physician that includes the patient’s health-related priorities, nurse’s assessment of the patient’s needs, and immediate actions to be taken), 3) Care Guide (succinct summary of the patient’s clinical status and plan of care), and 4) Action Plan (patient-friendly document that summarizes the self-management actions that the patient has agreed to complete). These forms allow the healthcare team and patient to prioritize their health needs and set goals. By improving patient collaboration and care coordination, incorporating standardized forms into the Guided Care model can broadly improve healthcare outcomes and reduce costs.
Stage of Development
Researchers developed and licensed the Guided Care model in 2001. In a pilot study, this model reduced insurance costs by 23% over a six-month period (Boult, 2008). In a randomized control trial at eight primary care practices with 800 patients in the Baltimore area (2006-2009), researchers demonstrated that this model improves the quality of care (Boult, 2008). In later separate case studies at Lahey Health with 1,500 patients, the accountable care organization achieved $12 million in savings in one year (Hostetter, 2016). The model received the 2009 Medical Economics Award. Johns Hopkins researchers are constantly improving the model, which now includes four standardized care-planning forms.
