Presentation on theme: "Engaging Patients in Guided Care"— Presentation transcript:
1 Engaging Patients in Guided Care Chad Boult, MD, MPH, MBAProfessor of Public Health, Medicine and NursingJohns Hopkins UniversityAlliance for Health Care ReformWashington DCMarch 5, 2010
2 Ms. Marian Chen 79 year old widow Retired teacher, lives alone Income: SS, pension and MedicareDaughter, lives 10 miles away with three teenagersFive chronic conditionsThree physiciansEight medications79 year-old, widowed, retired school teacherLives in an apartment with her catReceives SS, a pension, and FFS MedicareDaughter live 10 miles away, has 3 teenagers5 chronic conditions3 physicians8 medications
3 In 2009, Mrs. Chen had…6communityreferrals2home careagencies5 monthshomecarenursinghomesweeks sub- acute care3hospitaladmissions19outpatientvisits8meds22scriptsMrs.Chen8 Physicians, 6 Social Workers, 5 Physical Therapists, 4 Occupational Therapists, 37 NursesSeveral exacerbations (CHF, DM, HTN, CAD, OA)22 prescriptions for her 8 medications19 outpatient visits to three physicians3 hospitals admissions6 weeks in subacute care in two nursing homesFive months of home care from two agencies8 physicians, 6 SWs, 5 PTs, 4 OTs, 37 RNsReferred to six community agencies
4 Reduced work to half-time Considering nursing homes Mrs. ChenConfused by care, medsNon-adherentRelies on her daughterDaughterStressed outReduced work to half-timeConsidering nursing homesMrs. ChenConfused by care: does not followdiet, monitor weight or BP, only takes 50% of med dosesPoor quality of life: no preventive services or advance directiveCost: Paid $4,700 out-of-pocket for health care, confused by billsMedicare 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 monthlySupports chronic disease self-managementSmoothes transitions between care sitesCommunicates with providers in EDs, hospitals, specialty clinics, rehab facilities, home care agencies, hospice programs, and social service agencies in the communityEducates and supports caregiversFacilitates access to community servicesBoyd et al. Gerontologist Nov. 2007
8 Self-Management Assessment of patient’s values/priorities Patient/caregiver involved in planningMonthly follow-up reinforces adherenceMotivational interviewingSupport for family caregivers
9 Randomized TrialHigh-risk older patients (n=904) of 49 community-based primary care physicians practicing in 14 teamsPhysician/patient teams randomly assigned to receive Guided Care or “usual” careOutcomes measured at 8, 20 and 32 months
11 How Well Does Guided Care Work? A pilot test and the first year of a multi-site RCT show:Improved quality of careImproved physician satisfaction with careReduced strain for family caregiversHigh job satisfaction for nursesNet reduction in health care costsSylvia M et al. Disease Manag 2008Boyd C et al. JGIM Feb 2008Boult C et al. Journals of Gerontology Mar 2008Wolff et al. Journals of Gerontology June 2009Leff B et al. AJMC July 2009
12 Resources: Guided Care implementation manual On-line course for Guided Care nursesOn-line course for practice leaders
13 Grant Support John A. Hartford Foundation Agency for Healthcare Research and QualityNational Institute on AgingJacob and Valeria Langeloth Foundation
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