Guided Care

Region Within State: 
8 community-based primary care practices in the Baltimore-Washington, DC region
Project Category: 
Multi-Stakeholder
PROJECT STATUS
Target Start Date: 
Thursday, June 1, 2006
Pilot/Demo Length: 
36 months

Guided Care provides many aspects of a “patient-centered medical home” for the growing number of older adults with complex health needs. It is a model of proactive, comprehensive health care provided by physician-nurse teams for patients with several chronic conditions. It was designed to improve the quality of life and quality of care, as well as the efficiency of their treatment, for complex patients.

 

Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002. In creating the Guided Care model, the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management, disease management, self-management, transitional care, geriatric evaluation, and caregiver support models into primary care. Guided Care integrates these successful innovations into primary care to make evidence-based, state-of-the-art chronic care available from professionals the patient trusts.

 

In Guided Care, a registered nurse, who is based in a primary care office, works closely with 3-4 physicians and health information technology to provide state-of-the-art care for 50-60 chronically ill patients. In partnership with the primary care physician, the Guided Care nurse is responsible for the following clinical processes:

  • Assesses the patient at home.
  • Creates an evidence-based comprehensive “Care Guide” (a tool for providers that summarizes the patient’s conditions and medications, care providers, family members, and other important data in a succinct and professional format) and “Action Plan” (a patient-friendly version of the Care Guide).
  • Monitors the patient monthly.
  • Promotes patient self-management.
  • Smoothes the patient’s transitions between sites of care.
  • Coordinates the efforts of all the patient’s health care providers.
  • Assesses, educates and supports family caregivers.
  • Facilitates access to community resources.

 

Encouraged by results of a 1-year pilot, the Lipitz Center secured grant funding from the John A. Hartford Foundation, the Agency for Healthcare Research and Quality (AHRQ), the National Institute on Aging (NIA), and the Jacob and Valeria Langeloth Foundation to conduct a cluster-randomized controlled trial (cRCT) of Guided Care in 8 community-based primary care practices in the Baltimore-Washington DC region. The primary objective of the cRCT is to evaluate the effects of Guided Care on the quality, efficiency and clinical outcomes of health care for chronically ill older patients and their informal caregivers.

Type of Practices: 
Internal Medicine
CONVENING ENTITY/PROJECT CONTACTS
Convening Organization Name: 
Johns Hopkins Bloomberg School of Public Health
Primary Contact: 
Tracy Novak
E-mail: 
tnovak@jhsph.edu
Phone: 
410-614-1932
Participating Stakeholders: 

Kaiser Permanente Mid-Atlantic States, MedStar Physician Partners, Johns Hopkins HealthCare, Johns Hopkins Community Physicians, and the Centers for Medicare and Medicaid Services.

EXPECTED OR ACTUAL DEMOGRAPHICS OF PARTICIPATING PRACTICES
Number of Practices: 
8
Number of Participating Physicians: 
49
Physicians per practice: 
varies
Types of Practices: 
Internal Medicine and Family Medicine
Health Plan Lines of Business Included: 
Medicare fee-for-service, Tricare (also known as U.S. Family Health Plan, which covers retired military personnel and their dependents), and Kasier Permanente
Overall Number of Covered Lives: 
1212
Technology Characteristics at Start of Pilot: 

The Guided Care nurses used a secure web-based EHR that was created to support Guided Care. The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions. The Guided Care nurses used the EHR to do the following:

  • Enter new information about their patients, such as initial assessment data, changes in health status and 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 Guides 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.

 

Moving forward, Johns Hopkins is working with several HIT vendors to incorporate the EHR components required for Guided Care into existing and new commercial product lines.

Consumer Involvement: 

Our Stakeholder Advisory Committee included representatives of consumer groups (e.g., AARP, National Council on Aging). We conducted annual surveys of patients and caregivers. Lay people were recruited and trained to lead Chronic Disease Self-Management Program classes. Several patients and caregivers have provided testimonials at meetings and events.

PRACTICE TRANSFORMATION SUPPORT (INCLUDING TECHNOLOGY)
Focal areas of transformation: 

Guided Care is a well-defined model of care that primary care practices can fully implement in six-to-nine months.  Implementation involves hiring a registered nurse (who has completed a course in Guided Care Nursing and integrating the nurse into the practice.  Several forms of technical assistance are available to practices that wish to adopt Guided Care, including a detailed implementation manual, an online course in Guided Care Nursing, an accredited online course for physicians and other practice leaders, and guidance in selecting health information technology. Please visit www.MedHomeInfo.org for details.

Services participating practices have added as a result of their participation: 

Six of the seven practices that provided Guided Care in the cRCT have continued to provide Guided Care throughout the year following the study.

Technology that participating practices have added as a result of their participation: 

Three practices continue to use the Guided Care EHR.

Payment Model: 

During the cRCT, the costs of providing Guided Care were split between grant funding (50%) and two managed care partners (50%). Moving forward, we recommend that health insurers pay a monthly, risk-adjusted care management fee for eligible beneficiaries, as well as traditional fee-for-service payments and bonuses for high-quality care.

PROJECT EVALUATION
Types of data to be collected : 

Patients: health and functional status, quality of care, satisfaction with care, use/cost of care.

Caregivers: level of strain, health.

Providers: PCP satisfaction, Guided Care nurse satisfaction, organizational dynamics.

Which of the data types are being shared?: 

Several journal articles have been published with early results from the cRCT on improved quality of patients’ care, reduced utilization of services, reduced family caregiver strain, and improved physician satisfaction with chronic care (see the results section for citations). Additional data analysis and publications are in process.

Are the practices involved in the demonstration participating in any data sharing arrangements? If so please describe.: 

No.

Results to Share: 

Preliminary data indicate that Guided Care:

  • Improves the quality of patients’ care. After six months, Guided Care patients were twice as likely as usual care patients to rate the quality of their care highly. [Boult C et al. 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):321-327.] After 18 months, Guided Care patients were more than twice as likely as usual care patients to rate the quality of their care highly. [Boyd CM 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):235-242.]
  • Reduces the use and cost of expensive services.  After the first eight months of the study, Guided Care patients experienced, on average, 24% fewer hospitals days, 37% fewer skilled nursing facility days, 15% fewer emergency department visits, and 29% fewer home health care episodes, as well as 9% more specialist visits (not statistically significant). Based on current Medicare payment rates and Guided Care costs, these differences in utilization produce net savings for health care insurers. [Leff B et al. Guided Care and the Cost of Complex Health Care. Am J Manag Care 2009; 15(8):555-559.]
  • Reduces family caregiver strain. After six months, the Guided Care caregivers’ “strain” and “depression” scores were lower than the comparison (usual care) caregivers’ scores, especially among caregivers who provided more than 14 hours of weekly assistance. [Wolff JL et al. Caregiving and Chronic Care: The Guided Care Program for Families and Friends. Journal of Gerontol Med Sci 2009;64A(7):785-791. Wolff JL et al. Effects of Guided Care on Family Caregivers. Gerontologist 2009 Epub Aug 26.]
  • Improves physicians’ satisfaction with chronic care.  Compared to the physicians in the control group, the physicians who practiced Guided Care reported, after six months, significant positive effects on communicating with patients, communicating with family caregivers, educating family caregivers, motivating patients to participate in their care, referrals to community resources, and knowing patients’ medications. [Boult C et al. 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):321-327.]

 

Other Recognition

  • Guided Care won the American Public Health Association’s 2008 Archstone Foundation Award for Excellence in Program Innovation.  The Award, established by an endowment from the Archstone Foundation, recognizes one innovative model of health care for older Americans each year.
  • Guided Care won 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.
  • Guided Care was a finalist for the British Medical Journal Group’s 2010 Getting Research into Practice Award.
  • The Guided Care Program at Kaiser Permanente Mid-Atlantic States won the 2010 Case In Point Platinum Award for Case Management Provider Program and was a finalist in two other categories.
Relevant links: 

Please visit www.GuidedCare.org for details about Guided Care and visit www.MedHomeInfo.org for details about technical assistance on becoming a Guided Care medical home, plus other assistance for participants in the Medicare Medical Home Demonstration.