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Service Delivery Innovation Profile

Onsite Nurses Manage Care Across Settings to Increase Satisfaction and Reduce Cost for Chronically Ill Seniors


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Snapshot

Summary

Specially trained nurses work with primary care physicians in their offices to improve care for seniors with multiple chronic illnesses by coordinating care, facilitating transitions in care, and acting as the patient's advocate across health care and social settings. Nurses use an electronic health record and a variety of established methods, including disease management, case management, transitional care, self-management, lifestyle modification, caregiver education and support, and geriatric evaluation and management. The program, known as "Guided Care," has significantly increased patient and family perceptions of quality, improves physician satisfaction with chronic care, improves nurse job satisfaction, and may reduce costs and utilization.

Evidence Rating (What is this?)

Strong: The evidence consists of results from an eight-site, cluster-randomized controlled trial that measured patient and caregiver perceptions of quality; costs and utilization; caregiver strain; and physician and nurse satisfaction.
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Developing Organizations

Johns Hopkins Bloomberg School of Public Health
Baltimore, MDend do

Use By Other Organizations

Assuming that research trial results 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 have continued to provide Guided Care following the completion of the trial, and other managed care organizations have expressed an interest in the program. Information provided in April 2011 indicates that three organizations have executed a Guided Care license agreement with Johns Hopkins University, and seven license agreements are in negotiation.

Date First Implemented

2003
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Patient Population

Age > Aged adult (80 + years); Senior adult (65-79 years)end pp

Problem Addressed

Many older adults have multiple, costly chronic conditions, and these individuals often receive care from a myriad of health care providers, resulting in fragmented, uncoordinated care that hampers effective management of patients' health care needs and quality of life.
  • 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

What They Did

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Description of the Innovative Activity

The "Guided Care" program places a specially trained registered nurse, known as a Guided Care Nurse, onsite at a primary care practice; each guided care nurse coordinates care for 50 to 60 elderly patients who have multiple complex chronic conditions. Supported by an electronic health record (EHR) and using a variety of established methods, including disease management, case management, transitional care, self-management, lifestyle modification, caregiver education and support, and geriatric evaluation and management, each nurse works with two to five primary care physicians (PCPs), specialists, caregivers, and community resources to coordinate and improve patient care across health care providers and settings. Key elements of the program include the following:
  • 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.

Context of the Innovation

The Guided Care model was developed by a multidisciplinary team of clinicians and researchers at Johns Hopkins University beginning in 2001. This team identified the need to better support the care and care transitions of chronically ill older patients and wanted to integrate that care within the primary care setting. The team is supported by a Stakeholder Advisory Committee, composed of national leaders from important stakeholders in chronic care, including health care professionals, health insurers, health care delivery systems, nursing educators, consumers, community services, policy makers, and regulators. The team set out to design and evaluate a practical model of care that could succeed in most U.S. primary care practices.

Did It Work?

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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?)

Strong: The evidence consists of results from an eight-site, cluster-randomized controlled trial that measured patient and caregiver perceptions of quality; costs and utilization; caregiver strain; and physician and nurse satisfaction.

How They Did It

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Planning and Development Process

Key steps in the planning and development process include the following:
  • 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.
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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
Funding has been provided by a variety of sources. Johns Hopkins HealthCare and Kaiser Permanente Mid-Atlantic States each continue to employ several Guided Care Nurses.end fs

Tools and Other Resources

More information on the program is available at http://www.guidedcare.org/adopting-guided-care.asp. Contact the innovator for additional information and other tools for potential adopters including:
  • EHR functions
  • Overview of chronic disease self-management programs
  • Outline of the Guided Care Nurse curriculum
  • Guided Care Nurse job description and recruitment posting
An implementation manual, entitled Guided Care: A New Nurse-Physician Partnership in Chronic Care (Springer Publishing Company, 2009), provides detailed, practical information and advice on how to assess whether a practice should adopt Guided Care, and, if so, how to implement and finance the program.

Transformation: A Family's Guide to Chronic Care, Guided Care, and Hope by Tom Grundner (Fireship Press, 2010) describes Guided Care to chronically ill patients and their families; the book is available in English and Spanish, in hard copy and electronic formats, and an audio version is coming soon.

Information on a "Guided Care Nursing" online course and the American Nurses Credentialing Center's new Certificate in Guided Care Nursing is available at: http://www.hopkinsmedicine.org/institute_nursing/.

Adoption Considerations

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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.

Use By Other Organizations

Assuming that research trial results 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 have continued to provide Guided Care following the completion of the trial, and other managed care organizations have expressed an interest in the program. Information provided in April 2011 indicates that three organizations have executed a Guided Care license agreement with Johns Hopkins University, and seven license agreements are in negotiation.

Additional Considerations

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

More Information

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Contact the Innovator

Chad Boult, MD, MPH, MBA
Director, Improving Healthcare Systems
Patient-Centered Outcomes Research Institute
1828 L St., Suite 900
Washington, DC 20036
Phone: 202-827-7727
E-mail: cboult@jhsph.edu

Innovator Disclosures

Dr. Boult has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Selected references are listed below; a full list of references is available at http://www.guidedcare.org/program-history-results.asp.

Boyd C, Boult C, Shadmi E, et al. Guided care for multimorbid older adults. Gerontologist. 2007;47(5):697-704. [PubMed]

Wolff JL, Giovannetti ER, Boyd CM, et al. Effects of guided care on family caregivers. Gerontologist. 2010;50(4):459-470. [PubMed]

Marsteller J, Hsu YJ, Reider L, et al. Physician satisfaction with chronic care processes: a cluster-randomized trial of guided care. Ann Fam Med. 2010;8(4):308-315. [PubMed]

Boyd CM, Reider L, Frey K, et al. 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):235-42. [PubMed]

(added April 2011) Boult C, Reider L, Leff B, et al. The effect of guided care teams on the use of health services: results from a cluster-randomized controlled trial. Arch Intern Med 2011;171(5):460-466. [PubMed]

Footnotes

1 Agency for Healthcare and Research Quality. Preventing disability in the elderly with chronic disease. Research in Action. 2002 April;3. Available at: http://www.ahrq.gov/research/elderdis.htm#CDSMPReduced.
2 Thorpe KE, Howard DH. The rise in spending among Medicare beneficiaries: the role of chronic disease prevalence and changes in treatment intensity. Health Aff (Millwood). 2006;25(5):w378-88. [PubMed]
3 Anderson G. Chronic conditions, expert voices. NIHCM Foundation, January 2002.
4 Horvath J. Chronic conditions in the US: implications for service delivery and financing. Presentation 2003 Oct 10. Available at: http://archive.ahrq.gov/news/ulp/hicosttele/sess2/horvathtxt.htm.
5 Wennberg JE, Fisher ES, Goodman DC, et al. Tracking the care of patients with severe chronic illness. The Dartmouth Institute for Health Policy and Clinical Practice: the Dartmouth Atlas of Health Care 2008. Available at: http://www.dartmouthatlas.org/downloads/atlases/2008_Chronic_Care_Atlas.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
6 Ash AS, Ellis RP, Pope GC, et al. Using diagnoses to describe populations and predict costs. Health Care Financ Rev. 2000;21(3):7-28. [PubMed]
7 Boyd CM, Reider L, Frey K, et al. 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):235-42. [PubMed]
8 Wolff JL, Rand-Giovannetti E, Palmer S, et al. Caregiving and chronic care: the guided care program for families and friends. J Gerontol A Biol Sci Med Sci. 2009;64(7):785-91. [PubMed]
9 Wolff JL, Giovannetti ER, Boyd CM, et al. Effects of guided care on family caregivers. Gerontologist. 2010;50(4):459-470. [PubMed]
10 Boult C, Reider L, Leff B, et al. The effect of guided care teams on the use of health services: results from a cluster-randomized controlled trial. Arch Intern Med. 2011;171(5):460-466. [PubMed]
11 Marsteller J, Hsu YJ, Reider L, et al. Physician satisfaction with chronic care processes: a cluster-randomized trial of guided care. Ann Fam Med. 2010;8(4):308-315. [PubMed]
12 Boult C, Reider L, Frey K, et al. The early effects of "Guided Care" on the quality of health care for multi-morbid older persons. J Gerontol A Biol Med Sci. 2008;63(3):321-7. [PubMed]
13 Public Law 111-148: The Patient Protection And Affordable Care Act. (124 Stat. 119 through 124 Stat. 1025; Date: March 23, 2010, enacted H.R. 3590). Text from United States Public Laws. Available at: http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf.
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: October 17, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: October 23, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: June 15, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

Back Story
Feedback from patients, primary care doctors, and caregivers, as well as Guided Care Nurses (GCNs) themselves, on the impact of the Guided Care program has been positive. The experiences of participants illustrate key aspects of the program that resonate among patients and providers. In-home assessment of the patient by a...

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