Primary Care

Study shows Guided Care benefits family caregivers, chronically ill older adults, and physicians, and may reduce costs

As the U.S. population ages, the number of older adults with chronic health conditions is increasing. Often, the burden of care falls upon family members and friends. This can cause high levels of stress among caregivers and subsequent poor perceptions of care in this elderly population. Guided Care is a new model of care delivery that attempts to improve care for these individuals. At its core is the role of a registered nurse who is based in a primary care practice and works with three to four physicians to manage all aspects of care, support family members, and facilitate community resources for older patients with multiple chronic conditions.

A 32-month randomized controlled trial, led by Chad Boult, M.D., M.P.H., M.B.A., of the Johns Hopkins Bloomberg School of Public Health, is evaluating the effects of the Guided Care model on older patients with multiple chronic conditions, family caregivers, primary care practices, and Guided Care nurses. The study is supported in part by the Agency for Healthcare Research and Quality (HS14580). Papers demonstrating early results of the study are briefly discussed here.

Giddens, J. F., Tanner, E., Frey, K., and others (2009). "Expanding the gerontological nursing role in Guided Care." Geriatric Nursing 30(5), pp. 358-364.

This article describes the role of the Guided Care nurse, including how best to prepare nurses to deliver components of the Guided Care model. Based in the primary care practice, a Guided Care nurse is expected to provide comprehensive care to 50 to 60 older patients with complex health care needs. A key component of this role is to facilitate health care by acting as a liaison between older adults and their caregivers, the primary care provider, specialists, and various health care agencies. Other clinical activities carried out by the nurse include patient assessment, the creation of an evidence-based care guide, monthly monitoring, encouraging patient self-management, coordinating care, smoothing transitions, providing education and support to caregivers, and assessing community resources. Nurses learn these eight clinical activities and competencies through a 6-week course organized into four units. After training, monthly meetings provide opportunities for these nurses to enhance self-confidence, master their role, receive peer support, and obtain ongoing education.

Boyd, C. M., Reider, L., Frey, K., and others (2010). "The effects of Guided Care on the perceived quality of health care for multi-morbid older persons: 18-month outcomes from a cluster-randomized controlled trial." Journal of General Internal Medicine 25(3), pp. 235-242.

The researchers determined the effects of Guided Care on how patients perceived the quality of health care they received from their health care team. Older patients received telephone calls during which they were asked 20 validated questions about their ongoing care. They were asked, for example, how well their care was organized, if they were asked for input on their treatment plan, and if they received a list of things they could do to improve their health. Those who received Guided Care had two times greater odds of rating their overall chronic care highly compared with controls who received usual care. Guided Care recipients also were significantly more likely to report higher-quality coordination of care and decision support. Guided Care recipients tended to have greater odds of rating their care as high quality when it came to goal setting, problem solving, and patient activation, although this was not statistically significant.

Marsteller, J., Hsu, Y. J., Reider, L., and others (2010, July). "Physician satisfaction with chronic care processes: A cluster-randomized trial of Guided Care." Annals of Family Medicine 8(4), pp. 308-315.

In this study, the researchers randomly assigned 14 teams of physicians (and their chronically ill older patients) to provide either Guided Care or usual care. They surveyed the physicians at baseline and 1 year later about their satisfaction with chronic care processes, time spent on chronic care, knowledge of their chronically ill older patients, and care coordination provided. Compared with the usual care physicians, those in the Guided Care group rated their satisfaction with patient/family communication and their knowledge of the clinical characteristics of their chronically ill older patients significantly higher. Other differences did not reach statistical significance.

Wolff, J. L., Rand-Giovannetti, E., Palmer, S., and others (2009). "Caregiving and chronic care: The Guided Care Program for Families and Friends." The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences 64A(7), pp. 785-791.

The ongoing trial of Guided Care with 14 primary care physician teams showed that at the 6-month followup, caregivers participating in the Guided Care model had lower depression and caregiver strain compared with controls, especially among caregivers who provided more than 14 hours of weekly assistance to older adults with complex health-related needs. The Guided Care Program for Families and Friends included an initial meeting between the nurses and the patient's caregivers, education and referral to community resources, coaching family members on a regular basis, a six-session workshop, and 1-hour monthly support groups for family members to share their experiences.

Wolff, J. L., Giovannetti, E. R., Boyd, C. M., and others (2010). "Effects of Guided Care on family caregivers." The Gerontologist, 50(4), pp. 459-470.

This article presents 18-month followup outcomes data about the effects of Guided Care on family caregivers. Caregivers completed surveys if their elderly loved ones were still alive and participating in the Guided Care study. Measured outcomes included caregiver depressive symptoms, caregiver strain, quality of care reported by the patient, and personal productivity. The research team found no statistically significant differences between intervention and control groups in depression, strain, and productivity at 18 months. However, caregivers participating in the Guided Care model reported the overall quality of care received by patients to be significantly better than caregivers of control group patients. Quality of care was reported to be significantly better by Guided Care-group caregivers across several dimensions, including goal setting, coordination of care, decision support, and patient activation.

Leff, B., Reider, L., Frick, K., and others (2009). "Guided Care and the cost of complex healthcare: A preliminary report." The American Journal of Managed Care 15(8), pp. 555-559.

Using insurance claims, the study team compared the health services used by patients who received Guided Care with the health services used by patients who received usual care during the first 8 months of the trial of Guided Care. Guided Care patients experienced, on average, 24 percent fewer hospital days, 37 percent fewer skilled nursing facility days, 15 percent fewer emergency department visits, and 29 percent fewer home health care episodes, as well as 9 percent more specialist visits (not statistically significant). Based on current Medicare payment rates and Guided Care costs, Guided Care produced a net savings of $75,000 per Guided Care nurse (average caseload of 55 high-risk patients) per year to the health care insurer, two-thirds of which accrued from reductions in hospital utilization.

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