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The Roger C. Lipitz Center for Integrated Health Care

The Guided Care Innovations

Guided Care is based on previously successful innovations in chronic care. The Guided Care Nurse (GCN) uses an Electronic Health Record (EHR) and works closely with the patient, the family, and the primary care physician in conducting eight clinical processes:

  1. Assessing the Patient and Primary Caregiver at Home: Using standardized instruments, the GCN performs an initial assessment of the patient’s medical, functional, cognitive, affective, psychosocial, nutritional, and environmental status during a home visit. The GCN also asks the patient to identify his or her highest priorities for optimizing health and quality of life.

  2. Creating an Evidence-based Care Plan: The EHR merges these individual assessment data with evidence-based “best practice” recommendations to create a preliminary “Care Guide” that lists medical and behavioral plans for managing and monitoring each of the patient’s chronic conditions. The GCN and the primary care physician then personalize this preliminary Care Guide to align it with the unique circumstances of the individual patient. The GCN discusses the preliminary Care Guide with the patient and caregiver – and modifies it further for consistency with their preferences, priorities, and intentions. The final Care Guide provides all involved health care professionals with a concise summary of the patient’s status and plans; it is updated regularly by the GCN. A patient-friendly version, called “My Action Plan” is written in lay language and displayed prominently in the patient’s home.

  3. Promoting Patient Self-Management: The GCN promotes the patients’ self-efficacy in managing their chronic conditions by referring them to a free, local 15-hour (6 session) chronic disease self-management (CDSM) course, which is led by trained lay persons and supported by the GCN. In this course, developed at Stanford University, the patients learn to refine and implement their Action Plans.

  4. Monitoring the Patient’s Conditions Monthly: With reminders from the EHR, the GCN monitors each patient at least monthly by telephone to detect and address emerging problems promptly.  When problems appear, the GCN discusses them with the primary care physician and takes appropriate action.  On weekdays, the GCN is directly accessible by telephone to the patient and caregiver for questions and concerns. The GCN uses motivational interviewing to facilitate the patient’s participation in care and to reinforce adherence to the Action Plan.  During coaching sessions, the GCN expresses empathy, clarifies discrepancies between current behavior and health goals, avoids arguing, and supports self-efficacy.

  5. Coordinating the Efforts of All Health Care Providers: The GCN coordinates the efforts of all the health care professionals who treat Guided Care patients in emergency departments (EDs), hospitals, rehabilitation facilities, offices, nursing homes, and at home.  Using the Care Guide as a tool, the GCN ensures that all providers are aware of the patient's complete medical status and plan of care. 

  6. Smoothing 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, and keeping the primary care physician informed of the patient’s status.

  7. Educating and Supporting the Caregiver:  For the family or other unpaid caregivers of patients with functional impairment or difficulty with health care tasks, the GCN offers individual assistance, including an in-person assessment and ad-hoc telephone consultation.

  8. Facilitating Accessing to Community Resources: The GCN facilitates access to community resources to meet the patient’s and caregiver’s needs.  The GCN may suggest, for example, that the patient or caregiver contact a transportation service, Meals-on-Wheels, the Area Agency on Aging, or the local Alzheimer’s Association.