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November 18, 2011

Free Guided Care Training and Tools Available for Accountable Care Organizations Seeking to be Part of Medicare Shared Savings Program

The Roger C. Lipitz Center for Integrated Health Care at the Johns Hopkins Bloomberg School of Public Health will offer free training and technical assistance for organizations that seek to use the Guided Care model to participate in the Medicare Shared Savings Program. The Centers for Medicare & Medicaid Services (CMS) developed the Shared Savings Program to improve care quality and reduce costs for Medicare beneficiaries and is now accepting applications for an April 2012 launch as part of the Affordable Care Act. The free assistance is made possible by a grant from the John A. Hartford Foundation. 

Guided Care is a model of comprehensive primary care in which a registered nurse, co-located in a primary care practice, partners with 2-5 physicians and other team members to provide coordinated, patient-centered, cost-effective care to 50-60 patients with multiple chronic conditions. A three-year, multi-site, cluster-randomized controlled trial showed that, compared to traditional care, Guided Care significantly improved the quality of patients’ care and physicians’ satisfaction with chronic care. Results also include a reduction in the use of expensive services, especially in well-managed health care delivery systems.

“The Guided Care model can help Accountable Care Organizations (ACOs) serve chronically ill adults,” said Chad Boult, MD, MPH, MBA, leader of the multidisciplinary team that developed Guided Care and a professor with the Bloomberg School’s Department of Health Policy and Management. “We have been testing and perfecting Guided Care for nearly 10 years, and we are pleased to assist health care providers improve the quality, efficiency and outcomes of care for their high-risk patients.”

The Medicare Shared Savings Program incentivizes hospitals and doctors to work together to improve the quality and efficiency of health care. Organizations that meet quality targets will get to share in the program’s cost savings.

A limited supply of the following resources is available for free to organizations that plan to implement the principles of Guided Care as they become ACOs:

Also available is a low-cost, online course for practice leaders. This asynchronous, CME (Continuing Medical Education)-eligible, nine-module course provides physicians, practice administrators and other practice leaders with an introduction to the competencies that facilitate effective physician practice within ACOs. Tuition is $15 per module. Physicians receive a certificate and one CME credit per one-hour module. The course is offered by the Center for Teaching and Learning with Technology at the Johns Hopkins Bloomberg School of Public Health.

For more details about this assistance, please visit

About Guided Care

The Guided Care model is designed to improve quality of care and quality of life, while improving the efficiency of treating the sickest and most complex patients. Guided Care teams consist of a registered nurse, two to five physicians and the other members of an office team who work together to assess patients in their homes, create an evidence-based care plan, monitor patients proactively, smooth transitions between sites of care, promote self-management, coordinate the efforts of all providers, educate and support caregivers and facilitate access to community resources.

A three-year, multi-site, cluster-randomized controlled trial found that Guided Care patients were more than twice as likely as “usual” primary care patients to rate the quality of their care highly, and that Guided Care physicians were more satisfied with the chronic care they provided. In an integrated health care delivery system, patients who received Guided Care tended to use fewer expensive health services than those who received usual primary care: 15% fewer hospital admissions, 49%  fewer readmissions, 47% fewer skilled nursing facility (SNF) admissions and 17% fewer emergency department visits.* 

The trial involved 49 physicians, 904 older patients and 308 family members in eight locations in the Baltimore-Washington, D.C. region. It was funded by a private-public partnership of the John A. Hartford Foundation, the Agency for Healthcare Research and Quality, the National Institute on Aging and the Jacob and Valeria Langeloth Foundation,

Several organizations have already licensed the Guided Care model, including Harvard Vanguard Medical Associates, Kaiser Foundation Health Plan of the Mid-Atlantic States Inc., MidMichigan Home Care, Piedmont Community Health Plan, and Tufts Health Plan Medicare Preferred. The University of San Francisco has utilized materials from Guided Care in its work to improve the care and reduce the costs of high-risk patients. For more information about Guided Care, visit

* Only the reduction in SNF admissions was statistically significant.

About the John A. Hartford Foundation

Founded in 1929, the John A. Hartford Foundation is a committed champion of training, research and service system innovations that promote the health and independence of America's older adults. Through its grantmaking, the Foundation seeks to strengthen the nation's capacity to provide effective, affordable care to this rapidly increasing older population by educating "aging-prepared" health professionals (physicians, nurses, social workers), and developing innovations that improve and better integrate health and supportive services. The Foundation was established by John A. Hartford. Mr. Hartford and his brother, George L. Hartford, both former chief executives of the Great Atlantic and Pacific Tea Company, left the bulk of their estates to the Foundation upon their deaths in the 1950s. Additional information about the Foundation and its programs is available at

Media contact, Johns Hopkins Bloomberg School of Public Health : Tim Parsons, director of Public Affairs, at 410-955-7619 or