As Americans live longer, many develop chronic health conditions that require complex care. By the year 2025, more than 25% of the U.S. population will be living with multiple chronic conditions, and the cost for managing their care is expected to reach $1.07 trillion. The fragmented U.S. healthcare system often does not serve the sickest very well. The Institute of Medicine calls the current system "a nightmare to navigate." Many of the elderly and those who care for them would agree. A number of solutions have been developed to address this problem, but none is as personal and comprehensive as Guided Care. In Guided Care, a specially educated registered Guided Care Nurse works in partnership with a team of primary care physicians to provide coordinated, patient-centered care to chronically ill patients. The Guided Care Nurse assesses, plans, monitors, educates, coordinates, empowers, and works with community agencies to ensure that the patient's goals for healthcare are met. A secure web-accessible electronic health record assists the Guided Care Nurse with drug interaction alerts, evidence-based guidelines, reminders, and tracking of encounters with health care professionals. While disease management and case management programs often focus on one or a few chronic conditions, the Guided Care Nurse manages all of a patient's health care needs in the home, the doctors' offices, the hospital, and the community. Guided Care is customized to address each patient's unique health care needs. The program is based on proven innovations and the Chronic Care Model. To view a short video clip about Guided Care, click here.
- Guided Care received 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 care for older Americans each year.
- Guided Care received the 2009 Medical Economics Award for Innovation in Practice Improvement cosponsored by the American Academy of Family Physicians, the Society of Teachers of Family Medicine, and Medical Economics magazine. The award acknowledges creative, cutting-edge strategies developed effectively to redesign an office-based practice and promote patient participation and practice growth.
- The Roger C. Lipitz Center for Integrated Health Care at the Johns Hopkins Bloomberg School of Public Health was a finalist for the British Medical Journal Group's 2010 Getting Research into Practice Award for the Center's work on Guided Care. The finalists are recognized as having a strong evidence base with a clear and long-term impact on outcomes that matter to patients.
- The Guided Care Program at Kaiser Permanente Mid-Atlantic States won the 2010 Case In Point Platinum Award for Case Maangement Provider Program and was a finalist in two other categories, the Integrated Case Management Program and the Overall Case Management Program. Each award recognizes the most successful and innovative case management program working to improve health care across the care continuum.
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 online course for physicians and other practice leaders, and guidance in selecting health information technology. For more information, please visit www.MedHomeInfo.org.
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