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The Roger C. Lipitz Center for Integrated Health Care

Frequently Asked Questions about Guided Care

1. What is Guided Care?
Guided Care is a practical, interdisciplinary model of health care designed to improve the quality of life and efficiency of resources used for persons with medically complex health conditions. A Guided Care Nurse works in partnership with several primary care physicians to provide coordinated, patient-centered, and cost-effective care to 50-60 of their chronically ill patients. 

2. What is the role of a Guided Care Nurse?
The Guided Care Nurse uses an Electronic Health Record and works closely with the patient, the family and the primary care physician in conducting eight clinical processes:

3. What is unique about Guided Care?
Guided Care integrates several previously successful innovations (see processes in #2) with primary care to make evidence-based, state-of-the-art health care for chronic conditions available consistently from professionals the patient trusts. Guided Care is easily adopted by primary care practices.

4. What are the fundamental elements of Guided Care?

5. How does Guided Care differ from care/case management?
Guided Care includes care/case management as well as several other important processes. Unlike most care/case managers, the Guided Care Nurse:

6. How does Guided Care differ from disease management?
Like disease management, Guided Care provides patients with periodic health education, reminders and encouragement to adhere to evidence-based guidelines. In addition, the Guided Care Nurse also:

7. What is the status of Guided Care?
A multidisciplinary team of investigators at Johns Hopkins University and experts from across the nation have:

8. What are patients and family caregivers saying about Guided Care?
Feedback from patients and family caregivers in the Guided Care randomized controlled trial has been very positive.  Anecdotal comments include: “It is like having a nurse in the family!” “I think I can do this, now that I have you.”  “Thank you for all of your help. Since you’ve been working with me, I’m feeling better.”  “It is about time someone put together a program like this!”  "It is hard to put into words a way to thank you for all you did for my mom and me - you made a significant difference in our lives."

9. What are primary care physicians saying about Guided Care?
Initial comments from the primary care physicians who have worked with Guided Care Nurses in the pilot study and the randomized controlled trial have been uniformly complimentary.  They appreciate the role that the Guided Care Nurse serves in providing coordinated care and improving the health of their patients.  Anecdotal comments include: “It’s like having the hand of the doctor in the patient’s home.” “I developed a closer relationship with my patients through the Guided Care Nurse.” “The Guided Care Nurse saved me time, and made my practice more efficient.” “Because of her [the Guided Care Nurse’s] coordination, I was better able to care for my patients.”  Click here to view a short video clip from physicians who participated in the Guided Care pilot (via Real Player technology).

10. What are Guided Care Nurses saying about Guided Care?
Feedback from the Guided Care Nurses in the randomized controlled trial has been extremely favorable. Anecdotal comments include: “I’m practicing nursing the way it was originally envisioned – holistic patient care.”  “Patients appreciate immediate access to me and how I assist them through all parts of the system.”  “It is great to be in the primary care practice, working in partnership with the doctor.”

11. What does a Guided Care Nurse actually do, day-to-day?
Each day in the life of a Guided Care Nurse (GCN) is different, but may include a combination of: 

12. What are the requirements for becoming a Guided Care Nurse?
The ideal candidate is a licensed registered nurse with at least three years of home care, case management, community health and/or equivalent gerontologic nursing.  The nurse must have an affinity for working with chronically ill older patients and their caregivers, good communication skills, and flexible problem solving skills.  The nurse must also be comfortable using electronic health records.  All candidates must complete the online Guided Care Nurse curriculum and pass an exam to receive a Certificate in Guided Care Nursing from the American Nurses Credentialing Center (ANCC). Please note that the ANCC Certificate is not a certification, but rather a one-time recognition of professional achievement.

13. What is unique about the Guided Care Nurse curriculum?
Many of the skills needed for Guided Care are already possessed by many nurses.  Other skills may need refreshing: 

14. When is the Guided Care Nurse course offered?
For information or to register for the online course, go to If you have specific questions about the course, send an email to

15. What is a Care Guide and how is it used by health professionals?
The Guided Care Nurse generates the Care Guide from information in the patient’s electronic health record (see #17).  The Care Guide summarizes the patient’s conditions, medications, allergies, diet, physical activity, monitoring reports, care providers, family members, and other important data in a succinct, professional format.  It is provided to physicians and other health professionals during scheduled appointments and upon admission to emergency departments, hospitals, home care, rehabilitation, and other venues of care.

16. What is an Action Plan and how is it used by Guided Care patients?
From the Care Guide (see #15), the Guided Care Nurse generates a personalized Action Plan.  The Action Plan is written in lay language and displayed prominently in the home to remind the patient to take medicines on time, eat proper foods, engage in healthy physical activity, self-monitor, keep appointments with health care providers, and call for help when needed.

17. Describe the Electronic Health Record used in Guided Care.
The Guided Care Nurse uses an Electronic Health Record (EHR) that incorporates evidence-based guidelines for 15 chronic conditions and is secure (the information is not stored on the computer).  The nurse uses the EHR to:

18. What data will be available about Guided Care?
In 2003-2004, the pilot test measured the effects of Guided Care on:

In 2008-2010, the randomized controlled trial will report the effects of Guided Care on:

Contact Tracy Novak at 410-614-1932 or for more information or to request the publications.

19. What are the costs of implementing Guided Care?
The cost of implementing Guided Care is the Guided Care Nurse salary and benefits, office space and equipment (laptop computer and cell phone), monthly internet and phone fees, and travel expenses (to patient homes and hospitals).  Contact Tracy Novak at 410-614-1932 or for more information.

20. How can I implement Guided Care in my community?
Read the book "Guided Care: A New Nurse-Physician Partnership in Chronic Care" (Springer Publishing Company 2009), an implentation manual for practices that want to adopt Guided Care. Go to for more information or to order.

21. Where and I get more information about Guided Care?
Visit the website at or contact Tracy Novak at for more information.

22. What are the employment opportunities for a nurse who successfully completes the Guided Care Nursing course?
A nurse who successfully completes the Guided Care Nursing course will be well positioned to work in many "medical homes," health care organizations that provide comprehensive, coordinated, continous care to their patients, including those with chronic conditions who require complex services. Two national Medicare Medical Home Demonstrations will soon begin plus other demonstrations are underway in more than 30 states.  For details, please visit (scroll down the list) and for activity in the private sector.

23. What is the Guided Care Program for Families and Friends (GCPFF)?
The GCPFF, a component of Guided Care, supports caregivers of adults with complex health needs. The goals of the program are to improve patients' health and improve the well-being of their families and friends. The GCPFF includes five elements that are managed by the Guided Care nurse:

Anecdotal comments from families and nurses suggest that families’ ready and direct access to nurses so that they can pose emerging questions and troubleshoot concerns is a tremendous comfort to them. The fact that the nurses’ job explicitly includes both patients and their involved families, and that nurses roles’ include care coordination may simplify some of the challenges of chronic care for patients’ family members. In fact, after 18 months in the trial, families of Guided Care patients judged patients’ quality of chronic illness care to be significantly better than did family members of patients in the control group. Among employed caregivers, we also observed a trend at 18 months toward greater work productivity (e.g., less distraction while at work) by Guided Care caregivers.

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