Guided Care is a practical, interdisciplinary model of health care designed to improve the quality of life and efficiency of resources used for persons with medically complex health conditions. A Guided Care Nurse works in partnership with several primary care physicians to provide coordinated, patient-centered, and cost-effective care to 50-60 of their chronically ill patients. The Guided Care Nurse uses an Electronic Health Record and works closely with the patient, the family and the primary care physician in conducting eight clinical processes:
- Assessing the patient and primary caregiver at home
- Creating an evidence-based "Care Guide" and "Action Plan."
- Promoting patient self-management
- Monitoring the patient’s conditions monthly
- Coordinating the efforts of all the patient's health care providers
- Smoothing the patient’s transitions between sites and providers of care
- Educating and supporting family caregivers
- Facilitating access to community resources
Guided Care integrates several previously successful innovations (see processes in #2) with primary care to make evidence-based, state-of-the-art health care for chronic conditions available consistently from professionals the patient trusts. Guided Care is easily adopted by primary care practices. - A rigorous curriculum for ensuring that registered nurses possess the skills necessary to practice Guided Care
- A Guided Care Nurse co-located with several primary care physicians
- Patients with complex chronic conditions
- An electronic health record
- Eight clinical processes (see #2)
Guided Care includes care/case management as well as several other important processes. Unlike most care/case managers, the Guided Care Nurse: - Is based in the primary care physician’s office
- Works with the patient long-term, usually for life
- Provides intensive transitional care
- Uses motivational interviewing to help patients manage their conditions
- Provides education and support for family caregivers
Like disease management, Guided Care provides patients with periodic health education, reminders and encouragement to adhere to evidence-based guidelines. In addition, the Guided Care Nurse also: - Establishes a close personal relationship with the patient by conducting an initial comprehensive assessment in the patient’s home; by meeting face-to-face with the patient in the physician’s office, hospitals, and rehabilitation facilities; and by making follow-up home visits
- Provides comprehensive care for all of the patient’s conditions
- Works closely with the patient’s family caregivers
- Works closely with the patient’s primary care physician and office staff
- Facilitates the patient's access to community services
A multidisciplinary team of investigators at Johns Hopkins University and experts from across the nation have: - Conducted a one-year pilot study of Guided Care that suggested Guided Care improves the quality and efficiency of care, and is feasible and acceptable to physicians, patients and family caregivers
- Completed a 32-month, cluster-randomized controlled trial of Guided Care at eight urban and suburban community primary care practices in the Baltimore-Washington, D.C. area. This study assessed the effects of Guided Care on patients' quality of life, insurers’ costs, family caregivers’ strain, primary care office function, and physicians’ and nurses’ job satisfaction. Six-month data from the RCT show that Guided Care improves the quality of care, reduces health care costs, and produces high job satisfaction among physicians and nurses. Outcomes will be measured again at 18 and 32 months.
- Based on early results, two of the managed care organizations that participated in the trial have decided to pay for the costs of Guided Care for an additional year.
Feedback from patients and family caregivers in the Guided Care randomized controlled trial has been very positive. Anecdotal comments include: “It is like having a nurse in the family!” “I think I can do this, now that I have you.” “Thank you for all of your help. Since you’ve been working with me, I’m feeling better.” “It is about time someone put together a program like this!” "It is hard to put into words a way to thank you for all you did for my mom and me - you made a significant difference in our lives." Initial comments from the primary care physicians who have worked with Guided Care Nurses in the pilot study and the randomized controlled trial have been uniformly complimentary. They appreciate the role that the Guided Care Nurse serves in providing coordinated care and improving the health of their patients. Anecdotal comments include: “It’s like having the hand of the doctor in the patient’s home.” “I developed a closer relationship with my patients through the Guided Care Nurse.” “The Guided Care Nurse saved me time, and made my practice more efficient.” “Because of her [the Guided Care Nurse’s] coordination, I was better able to care for my patients.” Click here to view a short video clip from physicians who participated in the Guided Care pilot (via Real Player technology). Feedback from the Guided Care Nurses in the randomized controlled trial has been extremely favorable. Anecdotal comments include: “I’m practicing nursing the way it was originally envisioned – holistic patient care.” “Patients appreciate immediate access to me and how I assist them through all parts of the system.” “It is great to be in the primary care practice, working in partnership with the doctor.”
Each day in the life of a Guided Care Nurse (GCN) is different, but may include a combination of:
- Assessing a new patient. The GCN conducts an initial in-home assessment of a new patient. The GCN begins by asking the patient to identify his/her highest priorities for optimizing health and quality of life. The GCN then evaluates the patient’s medical, functional, cognitive, affective, psychosocial, nutritional, and environmental status.
- Drafting a new patient’s "Care Guide.” Back at the office, the GCN enters extensive assessment information into the Guided Care Electronic Health Record (EHR). The GCN then prints an evidence-based “Care Guide,” which will become a blueprint for the patient’s health care for the rest of his/her life.
- Completing a new patient’s Care Guide. The GCN meets with the primary care physician to personalize the Care Guide (see #15) according to the unique circumstances of the individual patient. Later the GCN discusses the Care Guide with the patient and family caregiver and modifies it further for consistency with their preferences, priorities, and intentions. The completed Care Guide provides a concise, comprehensive summary of the patient’s status and plans. The GCN then converts the information contained in the final Care Guide into a patient-friendly “Action Plan” (see #16), which is written in lay language and displayed prominently in the patient's home to remind the patient to take medicines on time, eat proper foods, engage in healthy physical activity, self-monitor, keep appointments with health care providers, and call for help when needed.
- Monitoring patients’ conditions. With reminders from the EHR, the GCN monitors each patient at least monthly by phone. The GCN also meets with patients during their regular office visits with their primary care physicians. The GCN is accessible by cell phone to patients and caregivers for problems that emerge between monitoring calls and office visits. The GCN discusses the patients with their primary care physicians, implements appropriate action, and updates Care Guides and Action Plans.
- Promoting self management. The GCN promotes patients’ self-efficacy in managing chronic conditions by referring them to a free, local 15-hour (6 sessions) chronic disease self-management (CDSM) course. The course, developed at Stanford University, is led by trained lay persons and supported by the GCN. In the course, patients learn to refine and implement action plans.
- Coaching. In conjunction with the monthly monitoring calls, the GCN uses motivational interviewing to facilitate the patient’s participation in care and to reinforce adherence to the Action Plan.
- Coordinating transitions between sites and providers of care. The GCN coordinates the efforts of all health care professionals as a patient enters an emergency department, hospital, rehabilitation facility, or nursing home. The GCN does not usurp the duties of other professionals, but instead provides each with current information (the patient’s Care Guide), explains the GCN role, visits the patient, helps plan and execute discharge and follow up, and meets with the patient after the transition to ensure that care is proceeding as planned.
- Smoothing the patient's transitions between sites of care. The GCN smoothes the patient's path between all sites and providers of care, focusing most intensively on transitions through hospitals. The GCN keeps the primary care physician informed of the patient’s status and updates the Care Guide and Action Plan.
- Educating and supporting family caregivers. For the family or other unpaid caregivers, the GCN offers individual and group assistance in the form of an initial assessment, information about resources, quarterly monitoring calls, and ad-hoc telephone consultation to address family caregivers' questions and concerns as they arise.
- Facilitating access to community resources. The GCN facilitates access to community resources to meet the needs of a patient or family caregiver. For example, the GCN may suggest that a patient or family caregiver contact a transportation service, Meals-on-Wheels, the Area Agency on Aging, a senior center or adult day care center, or the Alzheimer’s Association for additional supportive services.
The ideal candidate is a licensed registered nurse with at least three years of home care, case management, community health and/or equivalent gerontologic nursing. The nurse must have an affinity for working with chronically ill older patients and their caregivers, good communication skills, and flexible problem solving skills. The nurse must also be comfortable using electronic health records. All candidates must complete the online Guided Care Nurse curriculum and pass a certificate examination.
Many of the skills needed for Guided Care are already possessed by many nurses. Other skills may need refreshing: - Motivational interviewing for behavior change.
- Working with Care Guides (see #15) and Action Plans (see #16).
- Promoting self-management.
- Educating and supporting family caregivers.
- Coordinating transitional care.
- Facilitating access to community resources.
- Operating the Electronic Health Record (see #17).
For information or to register for the online course, go to http://www.ijhn.jhmi.edu. If you have specific questions about the course, send an email to GuidedCare@son.jhmi.edu.
The Guided Care Nurse generates the Care Guide from information in the patient’s electronic health record (see #17). The Care Guide summarizes the patient’s conditions, medications, allergies, diet, physical activity, monitoring reports, care providers, family members, and other important data in a succinct, professional format. It is provided to physicians and other health professionals during scheduled appointments and upon admission to emergency departments, hospitals, home care, rehabilitation, and other venues of care.
From the Care Guide (see #15), the Guided Care Nurse generates a personalized Action Plan. The Action Plan is written in lay language and displayed prominently in the home to remind the patient to take medicines on time, eat proper foods, engage in healthy physical activity, self-monitor, keep appointments with health care providers, and call for help when needed.
The Guided Care Nurse uses an Electronic Health Record (EHR) that incorporates evidence-based guidelines for 15 chronic conditions and is secure (the information is not stored on the computer). The nurse uses the EHR to: - Check a patient’s medications for possible adverse interactions.
- Generate new and revised Care Guides (see #15).
- Document Guided Care Nurse contacts with patients, families, and providers.
- Check for reminders about scheduled events or actions
In 2003-2004, the pilot test measured the effects of Guided Care on:
- Quality of Care. Boyd CM et al. A Pilot Test of the Effect of Guided Care on the Quality of Primary Care Experiences for Multimorbid Older Adults. J Gen Intern Med 2008;23(5):536-42.
- Effect on health care costs. Sylvia M et al. Guided Care: Cost and Utilization Outcomes in a Pilot Study. Dis Manag. 2008;11(1):29-36.
In 2008-2010, the randomized controlled trial will report the effects of Guided Care on: - Quality of Care. 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.
- Quality of Life
- Patient satisfaction with health care
- Health care utilization. Leff B et al. Guided Care and the Cost of Complex Health Care. Am J Manag Care 2009;15(8):555-559.
- Family caregiver strain. Wolff JL et al. Caregiving and Chronic Care: the Guided Care Program for Families and Friends. J Gerontol Med Sci 2009;64A(7):785-791.
- Practice environment
Contact Tracy Novak at 410-614-1932 or tnovak@jhsph.edu for more information or to request the publications.
The cost of implementing Guided Care is the Guided Care Nurse salary and benefits, office space and equipment (laptop computer and cell phone), monthly internet and phone fees, and travel expenses (to patient homes and hospitals). Contact Tracy Novak at 410-614-1932 or tnovak@jhsph.edu for more information.
Read the book "Guided Care: A New Nurse-Physician Partnership in Chronic Care" (Springer Publishing Company 2009), an implentation manual for practices that want to adopt Guided Care. Go to www.springerpub.com/guidedcare for more information or to order.
Visit the website at www.GuidedCare.org or contact Tracy Novak at tnovak@jhsph.edu for more information. A nurse who successfully completes the Guided Care Nursing course will be well positioned to work in many "medical homes," health care organizations that provide comprehensive, coordinated, continous care to their patients, including those with chronic conditions who require complex services. Two national Medicare Medical Home Demonstrations will soon begin plus other demonstrations are underway in more than 30 states. For details, please visit www.cms.hhs.gov/demoprojectsevalrpts/md/list.asp (scroll down the list) and www.pcpcc.net/content/pcpcc-pilot-projects for activity in the private sector.
If you have other questions, submit them here. |
