Onsite Nurses Work With Primary Care Physicians to Manage Care Across Settings, Resulting in Improved Patient Satisfaction and Lower Utilization and Costs for Chronically Ill Seniors

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, as described below:
  • 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. The guided care nurse also asks the patient to identify his/her priorities for optimizing health and quality of life. Caregivers are encouraged to be present for this 2-hour session. Information gathered during the assessment is entered into the program's EHR. (See below for more details on the program-specific EHR.)
  • Evidence-based care planning: Using data from the comprehensive assessment and evidence-based guidelines that are programmed into the EHR, 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."
    • Care Guide: The Care Guide, which is placed in the medical record and shared with other health professionals, covers medications, diet, physical activity, self-monitoring, health goals, and follow up care requirements.
    • Action Plan: This user-friendly two-page version of the Care Guide is given to the patient to be displayed on the patient's refrigerator door or in another visible place. The Action Plan reminds the patient when to take medications, provides guidance on recommended diet and exercise, displays weight and blood pressure goals, offers follow up care reminders, and lists disease-specific warning signs.
  • Promoting patient self-management: The guided care nurse promotes the patients' self-efficacy in managing their chronic conditions by referring them to a free, local, chronic disease self-management course. This structured course, led by two trained and certified lay leaders, consists of six 2-hour weekly sessions for 10 to 15 patients; it is designed to encourage patients to take greater control over their own health, including the ability to refine and implement their Action Plans.
  • Monthly monitoring of the patient's conditions: With reminders from the EHR, the guided care nurse monitors the patient at least monthly by telephone to detect and address emerging problems promptly. When problems appear, the guided care nurse discusses them with the PCP and takes appropriate action. The guided care nurse uses motivational interviewing to facilitate the patient’s participation in his or her care and to reinforce adherence to the Action Plan.
  • 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 in emergency departments, hospitals, rehabilitation facilities, physician offices, nursing homes, and at home. Using the Care Guide as a tool, the guided care nurse ensures that all providers are aware of the patient’s complete medical status and plan of care.
  • Smoothing transitions between sites of care: The guided care nurse smoothes 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 and group 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 do the following:
  • Enter new information about their patients, such as initial assessment data, changes in health status and prescription medications, laboratory test results, specialists' reports, and reminders for future events.
  • Check patients' medications for possible adverse interactions.
  • Generate new and revised evidence-based Care Guide for providers and Action Plans for patients.
  • Document contacts with patients, families, and health care providers.
  • Check for reminders of events or actions scheduled for each day.

References/Related Articles

Contact the Innovator

Roger C. Lipitz Center for Integrated Health Care
Department of Health Policy and Management
Johns Hopkins Bloomberg School of Public Health
624 N. Broadway, Room 693
Baltimore, MD  21205
Phone: (410) 955-6546
Fax: (410) 955-0470
E-mail: cboult@jhsph.edu

Results

• Higher satisfaction and lower costs in pilot study: A 2003 to 2004 pilot study of a partial version of the program that included 150 patients found that Guided Care enhanced the quality of care and reduced costs in comparison to older patients who received usual care.
  • Higher patient-reported quality: Program enrollees rated their quality of care more highly than did similar patients who received usual care, especially on patient-physician communication (mean Primary Care Assessment Survey score = 82.1 vs. 71.1) and comprehensive knowledge of the patient (mean Primary Care Assessment Survey score = 75.6 vs. 68.8).⁷
  • Lower costs: The average costs (as measured by insurance payments for services) were 23 percent lower over a 6-month period for program enrollees than for older patients who received usual care. Reduced hospital admissions (44 percent), hospital days (67 percent), and visits to emergency departments (52 percent) accounted for these savings.⁸
• Early RCT results also promising: The program was tested by Johns Hopkins in a cluster RCT with more than 900 patients and 300 family caregivers at 8 sites with 49 PCPs in the Baltimore-Washington, D.C. area. Early analysis of results suggest that the program improves patient perceptions of quality, significantly reduces utilization and costs, lowers levels of caregiver strain, and produces high satisfaction among physicians.
  • Higher quality as perceived by patients: After 6 and 20 months, Guided Care patients were twice as likely as usual care patients to rate the quality of their care highly.
  • Significantly lower costs and utilization: Total costs fell by 11 percent (equal to $1,365 per beneficiary per year). During the first 8 months of the study, Guided Care patients experienced fewer hospitals days (24 percent), skilled nursing facility days (37 percent), emergency department visits (15 percent), and home health care episodes (29 percent). Specialist visits increased by 9 percent, although this finding was not statistically significant. Based on current Medicare payment rates and Guided Care costs, these differences in utilization produce net savings for health care insurers.
  • Less family caregiver strain: After 6 months, the Guided Care caregivers' "strain" and "depression" scores were lower than for caregivers in the comparison (usual care) group, especially among caregivers who provided more than 14 hours of weekly assistance.
  • Higher physician satisfaction with chronic care: 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.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Nurse training and certification: The Guided Care program team developed a course to teach registered nurses the skills needed to practice Guided Care. This required training is designed to equip nurses to care for older adults with complex conditions through self-learning material and interactive workshops. The 34-module 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. Trainees receive content through a variety of learning activities, including five live webinars. The 6-week Web-based course is offered by the Institute for Johns Hopkins Nursing, an accredited provider of continuing nursing education, and has been endorsed by the National Gerontological Nursing Association. Completion of the course prepares the participant for an online examination leading to the American Nurses Credentialing Center’s new Certificate in Guided Care Nursing. Please visit http://www.ijhn.jhmi.edu for more information.
• 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. However, an online course (known as Practice Leaders for Medical Homes) was recently developed to make physicians aware of the competencies that facilitate effective physician practice within medical homes. More information is available at http://medhomeinfo.org/tools/physiciancourse/index.html.
• 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. The nurse must have an affinity for working with chronically ill older patients and their caregivers, good communication skills, ability to be flexible, and excellent problem-solving skills. The nurse must also be comfortable using EHRs. 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 (for which cost estimates are unavailable) and EHR-related expenses. Physician practices with an EHR could build program-specific elements into their existing systems. Tuition for the Guided Care Nurse Course and Certificate cost $1,900 per learner. Current members of the National Gerontological Nursing Association are eligible for discounted tuition of $1,500. Group and other professional organization discounts are available. Send an email to guidedcare@son.jhmi.edu for more information about all discounts and for additional course information.

Funding Sources

Agency for Healthcare Research and Quality; National Institute on Aging; John A Hartford Foundation; Jacob and Valeria Langeloth Foundation; Kaiser Permanente-Mid-Atlantic States; Johns Hopkins Bloomberg School of Public Health - Roger C. Lipitz Center for Integrated Health Care; Johns Hopkins HealthCare

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

• The program can easily be adopted by primary care practices because few changes are needed to the existing primary care clinic. The key aspects needed to start the program include the following: 
  • 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 case load: The case load 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 case load 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: Guide 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. One model being explored is the Centers for Medicare & Medicaid Services Medicare Medical Home Demonstration Project.⁹ Under this demonstration, Medicare proposes to pay practices a care management fee for managing chronically ill elderly individuals (in addition to traditional fee-for-service reimbursement for primary care services).
• 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

• Guided Care received the American Public Health Association's 2008 Archstone Foundation Award for Excellence in Program Innovation. This award, established by an endowment from the Archstone Foundation, recognizes one innovative model of health care for older Americans each year.
• “Guided Care is the winner of the 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.”

Use By Other Organizations

• As noted, eight primary care practices participated in an RCT. Assuming that final analysis of the results of the trial continue to be positive, program developers plan to disseminate the model throughout the American health care system. Two of the managed care partners in the trial will continue to provide Guided Care when the trial ends, and other managed care organizations have already expressed an interest in the program.