A Smarter Way to Manage Chronic Care
Why It's Needed
As health care organizations transition away from fee-for-service models, the need to efficiently manage high-risk patients has never been greater. Traditional care often falls short for those with multiple conditions, leading to fragmented services, unnecessary hospitalizations and higher costs. Many practices lack the resources or structure to provide the comprehensive, coordinated care these patients require.
Guided Care embeds specially trained nurses within primary care teams, ensuring patients receive seamless, personalized support across the continuum of care.
DR. BRUCE LEFF INTRODUCES The Guided Care® Model
Program Components
How Guided Care Works
Guided Care centers on a registered nurse who partners with primary care physicians and the broader care team to support a panel of 60–90 complex patients. This nurse serves as a consistent point of contact, working closely with patients, families, and providers to:
- Conduct in-home assessments
- Develop and update individualized care plans
- Monitor health status and respond to changes
- Coordinate communication among all care providers
- Smooth transitions between care settings
- Encourage patient self-management
- Educate and support family caregivers
- Connect patients to community resources
Program Components
Manuals and online resources support every stage of adoption. A three-year Johns Hopkins license provides access to the Guided Care service mark and essential implementation templates, including:
Key Steps
Implementation
Organizations can fully integrate Guided Care into primary care practices within 6–9 months. Key steps include:
- Designating a registered nurse who completes the Johns Hopkins online Guided Care Nursing course
- Embedding the nurse and the eight core Guided Care processes into daily practice
- Using clinical judgment or risk assessment tools to identify high-need patients
Transition to Value-Based Care
Guided Care delivers high-value care to complex patient populations. In a multi-site clinical trial, patients receiving Guided Care experienced higher quality care and reduced use of costly services, especially in integrated systems.
Developed by Dr. Bruce Leff and Dr. Chad Boult, Guided Care combines evidence-based processes with practical tools to help organizations succeed in value-based care environments.
Is This Product Right For Your Practice?
Guided Care is ideal for primary care organizations, health systems and payers seeking to:
- Improve outcomes for patients with chronic and complex conditions
- Reduce unnecessary hospitalizations and emergency visits
- Enhance care coordination and patient satisfaction
- Maximize value-based payment opportunities