1. Engaging Patients in Guided Care
Chad Boult, MD, MPH, MBA
Professor of Public Health, Medicine and Nursing
Johns Hopkins University
Alliance for Health Care Reform
Washington DC
March 5, 2010

2. Ms. Marian Chen 79 year old widow Retired teacher, lives alone
Income: SS, pension and Medicare
Daughter, lives 10 miles away with three teenagers
Five chronic conditions
Three physicians
Eight medications
79 year-old, widowed, retired school teacher
Lives in an apartment with her cat
Receives SS, a pension, and FFS Medicare
Daughter live 10 miles away, has 3 teenagers
5 chronic conditions
3 physicians
8 medications

3. In 2009, Mrs. Chen had… 6
community
referrals 2
home care
agencies
5 months
homecare
nursing
homes
weeks sub- acute care 3
hospital
admissions 19
outpatient
visits 8
meds 22
scripts
Mrs.
Chen
8 Physicians, 6 Social Workers, 5 Physical Therapists, 4 Occupational Therapists, 37 Nurses
Several exacerbations (CHF, DM, HTN, CAD, OA)
22 prescriptions for her 8 medications
19 outpatient visits to three physicians
3 hospitals admissions
6 weeks in subacute care in two nursing homes
Five months of home care from two agencies
8 physicians, 6 SWs, 5 PTs, 4 OTs, 37 RNs
Referred to six community agencies

4. Reduced work to half-time Considering nursing homes
Mrs. Chen
Confused by care, meds
Non-adherent
Relies on her daughter
Daughter
Stressed out
Reduced work to half-time
Considering nursing homes
Mrs. Chen
Confused by care: does not follow
diet, monitor weight or BP, only takes 50% of med doses
Poor quality of life: no preventive services or advance directive
Cost: Paid $4,700 out-of-pocket for health care, confused by bills
Medicare paid $42,400 to providers for her care
(not including medications)

5. The ¼ of Beneficiaries Who Have 4+ Chronic Conditions Account for 80% of Medicare Spending
Source: Medicare 5% Sample, 2001

6. What is Guided Care?
Comprehensive, coordinated care for patients with chronic conditions (and their families).
An RN located in the practice collaborates with 2-5 physicians in caring for of their most complex patients (and caregivers).

7. Nurse/physician team Assesses needs and preferences
Creates an evidence-based “care guide” and a patient-friendly “action plan”
Monitors the patient monthly
Supports chronic disease self-management
Smoothes transitions between care sites
Communicates with providers in EDs, hospitals, specialty clinics, rehab facilities, home care agencies, hospice programs, and social service agencies in the community
Educates and supports caregivers
Facilitates access to community services
Boyd et al. Gerontologist Nov. 2007

8. Self-Management Assessment of patient’s values/priorities
Patient/caregiver involved in planning
Monthly follow-up reinforces adherence
Motivational interviewing
Support for family caregivers

9. Randomized Trial
High-risk older patients (n=904) of 49 community-based primary care physicians practicing in 14 teams
Physician/patient teams randomly assigned to receive Guided Care or “usual” care
Outcomes measured at 8, 20 and 32 months

10. Baseline Characteristics
Guided Care
Usual Care
Age
77.2
78.1
Race (% white)
51.1
48.9
Sex (% female)
54.2
55.4
Education (12+)
46.4
43.4
Living alone
32.0
30.6
Conditions
4.3
HCC score
2.1
2.0*
ADL difficulty
30.9
29.3
Cognition (SPMS)
9.1
9.0

11. How Well Does Guided Care Work?
A pilot test and the first year of a multi-site RCT show:
Improved quality of care
Improved physician satisfaction with care
Reduced strain for family caregivers
High job satisfaction for nurses
Net reduction in health care costs
Sylvia M et al. Disease Manag 2008
Boyd C et al. JGIM Feb 2008
Boult C et al. Journals of Gerontology Mar 2008
Wolff et al. Journals of Gerontology June 2009
Leff B et al. AJMC July 2009

12. Resources: Guided Care implementation manual
On-line course for Guided Care nurses
On-line course for practice leaders

13. Grant Support John A. Hartford Foundation
Agency for Healthcare Research and Quality
National Institute on Aging
Jacob and Valeria Langeloth Foundation