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March 9, 2011       

Lipitz Center Providing Free Assistance to Help Medical Practices Improve Care for Chronically Ill Patients

The Roger C. Lipitz Center for Integrated Health Care at the Johns Hopkins Bloomberg School of Public Health is offering free technical assistance to help primary care practices and health care organizations, including accountable care organizations (ACOs), improve the quality and outcomes of health care for older adults with chronic illnesses. Through funding from the John A. Hartford Foundation, the Lipitz Center will offer health care providers information, education and technical support to promote the adoption of the Hopkins-developed Guided Care model for older adults with multiple chronic conditions.

Practices across the country are forming ACOs in response to provisions in the 2010 Affordable Care Act. ACOs are a new model for delivering health services that offers doctors, hospitals and others financial incentives for providing quality care at lower costs to a defined population. Guided Care is a team approach to health care that can shift organizational culture to improve collaboration. ACOs or patient-centered medical homes (PCMHs) can use the Guided Care model to manage populations of high-cost Medicare patients.

“Our goal is to help medical practices adopt and succeed as an ACO or a patient-centered medical home using the Guided Care model,” said Bruce Leff, MD, professor of medicine and health policy, as well as principal investigator of the project. “We are providing physicians, nurses, practice administrators, and other practice and health system leaders with immediate, convenient, affordable access to an array of resources that will help them provide better care.”

Several forms of technical assistance are free to medical practices that plan to implement Guided Care or the principles of Guided Care as they develop into ACOs or patient-centered medical homes. The resources include an implementation manual for health care providers titled “Guided Care: A New Nurse-Physician Partnership in Chronic Care;” an educational book for patients and families titled “Transformation: A Family’s Guide to Chronic Care, Guided Care, and Hope;” scholarships for registered nurses to an interactive, 6-week, 40-hour online course offered by the Institute for Johns Hopkins Nursing titled “Guided Care Nursing,” which leads to a Certificate in Guided Care Nursing from the American Nurses Credentialing Center; and an asynchronous, CME-eligible, 9-hour, 9-module, online course titled “Practice Leaders in Medical Homes” that provides physicians, practice administrators, and other practice leaders with an awareness of the competencies that facilitate effective practice within medical homes.

Guided Care is designed to improve the quality of life and the efficiency of resource use for persons with complex health care needs. A registered nurse, who is based in the primary care practice, works in partnership with 2 to 5 primary care physicians and other members of the care team to provide coordinated, patient-centered, cost-effective care to 50 to 60 of their chronically ill patients. The Guided Care nurse conducts in-home assessments, facilitates care planning, promotes patient self-management, monitors conditions monthly, coordinates the efforts of all health care professionals, smoothes transitions between sites of care, educates and supports family caregivers, and facilitates access to community resources. Primary care practices can fully implement Guided Care in 6 to 9 months. Implementation involves hiring a registered nurse who has a Certificate in Guided Care Nursing and integrating the nurse into the practice.

The Guided Care model was developed in 2002 by a team of researchers at Johns Hopkins and was tested at eight primary care sites in the Baltimore/Washington, D.C., area in a 32-month randomized controlled trial involving over 900 patients, 300 caregivers, and 48 primary care physicians. Guided Care improves the quality of patients’ care, improves caregivers’ perception of quality, improves physicians’ satisfaction with chronic care, improves nurses’ job satisfaction, and may reduce the use and cost of expensive services in well-managed systems like patient-centered medical homes and ACOs.

For information about Guided Care, please visit For details about the technical assistance, please visit

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 1950's. Additional information about the Foundation and its programs is available at

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