Baltimore, MD, United States
This is a 2-year cluster-randomized controlled trial of Guided Care, a novel enhancement of the quality and efficiency of health care for people with several chronic conditions. Half of 14 participating primary care teams were randomly selected to provide Guided Care, while the other half provides usual care.
In the Guided Care teams, a specially prepared registered nurse works closely with 2-5 primary care physicians in caring for their chronically ill older patients. For each Guided Care patient, nurse conducts an in-home assessment, develops an evidence-based "care guide" to address the chronic problems, monitors the patient proactively, coaches the patient in self-management, coordinates the efforts of all health care providers, smoothes the patient's transitions between sites of care, facilitates access to community resources, and educates and supports the family caregivers.
The study will evaluate the effects of Guided Care on patients' quality of life, quality of care, general health, functional ability, and use of health services. It will also assess the effects of Guided Care on family caregivers and primary care practices.