“High-value” care for patients with chronic conditions, complex needs and heavy use of care.
DR. BRUCE LEFF INTRODUCES The Guided Care® Model
As the U.S. health care system moves from “fee-for-service” to “value-based” payments, health care organizations have an ever-increasing need to reshape the care they provide so that it keeps their enrolled populations as healthy as possible, especially the high-utilizing sub-populations of people who have chronic conditions and complex health care needs. How to reshape their health care to improve the quality – while reducing the cost – of care for this high-risk sub-population remains a challenge to many organizations.
Guided Care® is a form of comprehensive health care that has been shown to increase the “value” (higher quality/lower cost) of healthcare for people with chronic conditions and complex health care needs. In the Guided Care model, a “Guided Care nurse,” who is based in a primary care office, works with two to five physicians and other members of the care team to provide coordinated, patient-centered, cost-effective health care to 60 to 90 of their complex, chronically ill patients. Working closely with patients, their families and their primary care providers, this specially-trained nurse:
1) conducts in-home assessments, 2) creates comprehensive care plans, 3) monitors patients’ conditions, 4) coordinates the efforts of all care providers, 5) smooths patients’ transitions between providers and sites of care, 6) promotes patient self-management, 7) supports and educates family caregivers and 8) facilitates patients’ access to community services.
A three-year Johns Hopkins License allows health care organizations to use the Guided Care® model – and the “Guided Care” service mark in marketing materials. The License also allows organizations to use four essential templates that facilitate the implementation of Guided Care:
- The Guided Care “Health History Questionnaire” (for the patient’s initial assessment)
- The Guided Care “Preliminary Care Guide” (the nurse’s initial plan, which is based on the initial assessment)
- The Guided Care “Care Guide” (the comprehensive care plan, which integrates input from the nurse, the primary care provider, the patient and the primary caregiver – and which is shared with other providers)
- The Guided Care “Action Plan” (the patient’s/caregiver’s version of the “Care Guide,” written in lay language and designed to promote patient self-management).
Guided Care® is a proven solution to the growing challenge of providing high-value health care for the high-risk members of populations whose total care will soon be covered by “value-based” (rather than “fee-for-service”) payments. The model, which is easily adopted, infuses several previously proven innovations into contemporary primary care to make excellent, comprehensive chronic care available from professionals whom the patient knows and trusts. Health care organizations that have provided Guided Care to older high-risk sub-populations have seen increases in the quality of care and decreases in the costs of care, both of which will result in “higher-value” care and, therefore, higher “value-based payments.”
What is required to implement Guided Care?
Guided Care is a well-defined model of comprehensive healthcare that organizations can fully implement in primary care practices within 6-9 months. Implementation involves:
1) Having within each practice a registered nurse who has completed the Hopkins online course in Guided Care Nursing
2) Integrating the nurse and the eight Guided Care processes into the practice
3) Adopting a method for identifying the practice’s high-risk, complex patients who will receive Guided Care, e.g., clinician judgment and/or mathematical risk estimation.
To use the Guided Care model and the “Guided Care” service mark, organizations need to obtain a license from Johns Hopkins University.
What is the measure of Guided Care’s success?
In a 32-month, multi-site, cluster-randomized clinical trial, chronically ill older patients who received Guided Care (compared to similar patients who received “usual care”) had:
- Higher quality of care
- Lower use of expensive services (especially in integrated delivery systems)
Furthermore, in anonymous surveys, primary care providers, family caregivers and Guided Care nurses all reported high levels of satisfaction with Guided Care.
IMPLEMENTATION RESOURCES -+
Guided Care Nursing course: An online course offered by the Institute for Johns Hopkins Nursing that prepares registered nurses to practice as Guided Care nurses
Guided Care implementation manual: a free, detailed manual that guides licensees through the process of implementing Guided Care in primary care practices (“Guided Care: a New Nurse-Physician Partnership in Chronic Care”)
Patient orientation manual: a free, detailed guide designed to help patients and their caregivers understand and obtain maximal benefit from participating in Guided Care
Consultation: free personal guidance through the consideration and implementation of Guided Care – by the “inventor” of Guided Care, Chad Boult, MD, MPH, MBA
WHY CHOOSE A JOHNS HOPKINS SOLUTION?
For 130 years, Johns Hopkins Hospital has led the way in both biomedical discovery and health care, establishing the standard by which others follow and build upon. This is one of many faculty-developed programs, protocols and services provided by Johns Hopkins HealthCare Solutions to improve health outcomes and reduce the cost of care.
Contact us to learn more about this solution and how it can benefit your organization.