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The Roger C. Lipitz Center for Integrated Health Care

Abstract of Research Grant Proposal

"Guided Care: Integrating High Tech and High Touch"

Health care for older Americans with chronic conditions is often fragmented and provider-centric. In response, a team of investigators at Johns Hopkins University has translated the scientific principles of seven successful innovations into one patient-centered system of care. Supported by evidence-based guidelines and state-of-the-art information technology, “Guided Care” underwent a 12-month pilot test on older primary care patients with complex needs. A specially trained Guided Care Nurse (GCN), based in a primary care practice, collaborates with two primary care physicians to provide seven services for 40-60 high-risk patients: comprehensive assessment and care planning, “best practices” for chronic conditions, self-management, healthy life styles, coordinating care, educating and supporting unpaid caregivers, and accessing community resources.

A 32-month cluster-randomized controlled trial was conducted at eight urban and surburban community primary care practices in the Baltimore-Washington, DC area. The multi-site study will measure the effects of Guided Care on the quality and outcomes of care for high-risk older persons, their unpaid caregivers, and their primary care physicians. The panels of 22 physicians in six practices was screened to identify 1350 high-risk older patients. After about 850 have given informed consent and baseline interviews, clusters of 1-3 physicians at each practice site were randomized to provide either Guided Care or usual care to their consenting patients. Each physician cluster in the Guided Care group incorporated a GCN into its practice; the physician clusters in the control group did not.

Interviews and queries of administrative databases will provide evaluative data at baseline and at 12, 18 and 32 months follow-up intervals. The primary outcome variable is the participants' Physical Health and Mental Health (SF-36 Summary Scales). Secondary outcome variables include: the quality of care; unpaid caregivers’ burden, costs, health, and satisfaction; and primary care physicians’ satisfaction. Intention-to-treat analyses will have 85% power (range 70-97%) to detect clinically meaningful differences between the two groups.

The study is designed to facilitate the prompt dissemination of Guided Care, if the results of the trial are favorable. A stakeholders’ advisory board, representing consumers, providers, delivery systems, insurers, regulators and policy-makers, will inform the operation and evaluation of the study – and it will facilitate the subsequent dissemination of its tools and technology throughout American health care.