Guided Care®

“High-value” care for patients with chronic conditions, complex needs and heavy use of care.



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.


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.

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