Skip Navigation

The Roger C. Lipitz Center for Integrated Health Care

The Guided Care Solution

Improving the Quality of Life for Older Americans with Complex Health Care Needs

As Americans live longer, many develop chronic health conditions that require complex care. By the year 2025, more than 25% of the U.S. population will be living with multiple chronic conditions, and the cost for managing their care is expected to reach $1.07 trillion. The fragmented U.S. healthcare system often does not serve the sickest very well. The Institute of Medicine calls the current system "a nightmare to navigate." Many of the elderly and those who care for them would agree.

A number of solutions have been developed to address this problem, but none is as personal and comprehensive as Guided Care. In Guided Care, a specially educated registered Guided Care Nurse works in partnership with a team of primary care physicians to provide coordinated, patient-centered care to chronically ill patients. The Guided Care Nurse assesses, plans, monitors, educates, coordinates, empowers, and works with community agencies to ensure that the patient's goals for healthcare are met. A secure web-accessible electronic health record assists the Guided Care Nurse with drug interaction alerts, evidence-based guidelines, reminders, and tracking of encounters with health care professionals.

While disease management and case management programs often focus on one or a few chronic conditions, the Guided Care Nurse manages all of a patient's health care needs in the home, the doctors' offices, the hospital, and the community. Guided Care is customized to address each patient's unique health care needs.  The program is based on proven innovations and the Chronic Care Model.  To view a short video clip about Guided Care, click here.


Ease of Adoption

Guided Care is a well-defined model of care that primary care practices can fully implement in six-to-nine months. Implementation involves hiring a registered nurse who has completed a course in Guided Care nursing and integrating the nurse into the practice. Several forms of technical assistance are available to practices that wish to adopt Guided Care, including a detailed implementation manual, an online course in Guided Care Nursing, an online course for physicians and other practice leaders, and guidance in selecting health information technology. For more information, please visit