Model of care for treating patients with multiple chronic conditions and complex needs.
DR. BRUCE LEFF INTRODUCES The Guided Care® Model
Caring for older adults with chronic conditions and complex health needs is becoming increasingly challenging. There is a lack of an efficient, cost-effective way to respond to the needs of patients with either chronic illnesses or co-morbidities.
The Guided Care® model consists of a Guided Care nurse, based in a primary care office, working with 2 to 5 physicians and other care team members to provide coordinated, patient-centered, cost-effective health care to 50 to 60 of their chronically ill patients. The nurse conducts in-home assessments, promotes patient self-management, facilitates care planning, monitors conditions, coordinates care efforts, smooths transitions, educates family caregivers, and more.
There is a three-year Johns Hopkins License to use the Guided Care® model and the service mark “Guided Care” in promotional materials to sell services, to enhance web presence, and for similar purposes. The License also allows you to apply in your practice the very specific Guided Care protocols. You will also be able to use of the following essential forms that will guide the implementation of Guided Care into your practice:
- Guided Care health history questionnaire;
- Guided Care preliminary care guide;
- Guided Care care guide;
- Guided Care action plan.
Guided Care® is a solution for the growing challenge of caring for older adults with chronic conditions and complex health needs, resulting in better care for patients and efficiencies for outpatient centers. The model takes several previously successful innovations and integrates them with primary care to make evidence-based, state-of-the-art, chronic care available continuously from professionals that the patient trusts. Guided Care is easily adopted by primary care practices.
A Guided Care nurse, based in a primary care office, works with 2 to 5 physicians and other members of the care team to provide coordinated, patient-centered, cost-effective health care to 50 to 60 of the practices’ chronically ill patients. The Guided Care nurse conducts in-home assessments, facilitates care planning, promotes patient self-management, monitors conditions monthly, coordinates the efforts of all health care professionals, smooths transitions between sites of care, educates and supports family caregivers, and facilitates access to community resources.
What does it take to implement Guided Care?
Guided Care is a well-defined model of care that primary care practices and outpatient clinics can fully implement in 6-9 months. Implementation involves (1) having a registered nurse(s) within the practice who has completed the course in Guided Care Nursing and (2) integrating the nurse into the practice. Organizations are required to obtain a license from Johns Hopkins University in order to use the Guided Care model and use the service mark “Guided Care” in promotional materials. The license also states that eight (8) services must be followed in the care of a practice’s chronically ill older patients;
- Assess the patient at home;
- Create for each patient an evidence-based, comprehensive “Care Guide” (a tool for providers that summarizes the patient’s conditions, medications, care providers, family members and other important data in a succinct and professional format) and an “Action Plan” (a patient-friendly version of the Care Guide);
- Promote patient self-management;
- Monitor the patient self-management;
- Monitor the patient’s conditions monthly;
- Undertake monthly proactive monitoring;
- Coordinate the efforts of all the patient’s health care providers;
- Smooth the patient’s transitions between sites and providers of care.
What is the measure of Guided Care’s success?
Based on a 32-month research trial (froom 2006-2009), it was demonstrated that Guided Care
- improves the quality of patients’ care,
- improves family caregivers’ perception of quality,
- improves physicians’ satisfaction with chronic care,
- produces high job satisfaction among Guided Care Nurses,
- may reduce the use of expensive services, especially in integrated healthcare delivery systems.
Can Guided Care be modified to better fit my organization?
Since Guided Care is a specific care model, the best results are obtained when following the model.
There are many websites and publications that can help practices learn how to transform and function successfully as comprehensive care practices. While these models have many names—medical home, comprehensive primary care, and accountable care—they share a team and patient-centered approach.
The Johns Hopkins Guided Care Chronic Care Management Webinar:
The Agency for Healthcare Research and Quality’s Patient Centered Medical Home Resource Center includes a citations database of journal articles, reports, policy briefs, and position statements on the medical home.
The American Academy of Family Physicians offers a comprehensive collection of information and resources to assist practices in becoming Patient-Centered Medical Homes.
The American College of Physicians provides information on understanding the Patient-Centered Medical Home, including cost, benefits and incentives, and links to tools and resources.
TransforMED, an affiliate of AAFP, offers a range of Medical Home Products and Services.
The National Committee for Quality Assurance’s (NCQA) Physician Practice Connections® – Patient-Centered Medical Home (PPC®-PCMH™-CMS) program builds upon NCQA’s Physician Practice Connections program to recognize primary care practices that function as patient-centered medical homes.
The Patient-Centered Primary Care Collaborative is a coalition of employers, consumer groups, patient quality organizations, health plans, labor unions, hospitals, physicians and others who work together to develop and advance the patient-centered medical home concept.
Medical Home News is a monthly newsletter for health care professionals interested in Patient Centered Medical Homes. Medical Home News is published by Health Policy Publishing LLC.
The National Transitions of Care Coalition has many tools, resources, and best practices for health care professionals to help enhance transitions of care.
The Chronic Disease Self-Management Program is a key resource for providers in meeting the requirements to become a Medicare Medical Home. The National Council on Aging (NCOA) has introduced Stanford’s CDSMP to 27 states. Click here for more information about CDSMP.
Project BOOST (Better Outcomes for Older adults through Safe Transitions) is a national initiative led by the Society of Hospital Medicine to improve the care of patients as they transition from hospital to home.
The Chronic Disease Electronic Management System is an easy-to-use free registry designed to assist medical providers in managing and reporting on patients with chronic health conditions. Visit for details.
Change Concepts supports the Patient-Centered Medical Home model of care in the Safety Net Medical Home Initiative.
Emmi Solutions, TransforMED and the PCPCC have partnered to create a web-based patient education tool. This engaging and educational multimedia experience helps patients understand the Patient-Centered Medical Home and their role in this collaborative health and wellness relationship with their primary care practice. Practices can place this patient education tool on a website for FREE.
Other consumer resources are available on the Patient-Centered Primary Care Collaborative website.
The National Transitions of Care Coalition has tools and resources for patients and families about care transitions.
The Johns Hopkins Patient Guide to Diabetes– An on-line resource where you can find information about managing diabetes and its complications.
WHY CHOOSE A JOHNS HOPKINS SOLUTION?
For more than 125 years, Johns Hopkins has led the way in both biomedical discovery and patient and population care. Faculty research often leads to innovative protocols, programs and services, establishing the standard by which others follow and build upon. Our goal: bring our knowledge and discovery to the world to improve the health outcomes of individuals and populations, improve the patient and provider experience, and reduce the cost of care.
Contact us to learn more about this solution and how it can benefit your organization.