Linking clinical practice and community resources the guided care model
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Linking Clinical Practice and Community Resources: The Guided Care Model. Chad Boult, MD, MPH, MBA Professor of Public Health, Medicine and Nursing Johns Hopkins University AHRQ 2009 Annual Conference September 14, 2009. Ms. Marian Chen. 79 year old widow Retired teacher, lives alone

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Linking Clinical Practice and Community Resources: The Guided Care Model

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Linking Clinical Practice and Community Resources:The Guided Care Model

Chad Boult, MD, MPH, MBA

Professor of Public Health, Medicine and Nursing

Johns Hopkins University

AHRQ 2009 Annual Conference

September 14, 2009


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


8 Physicians, 6 Social Workers, 5 Physical Therapists, 4 Occupational Therapists, 37 Nurses

22

scripts

6

community

referrals

8

meds

19

outpatient

visits

2

home care

agencies

Mrs.

Chen

3

hospital

admissions

5months

homecare

6

weeks sub- acute care

2

nursing

homes

In 2009, Mrs. Chen has had…


Mrs. Chen

  • Confused by care, meds

  • Poor quality of life

  • High out-of-pocket costs

  • Daughter

  • Stressed out

  • Reduced work to half-time

  • Considering nursing homes

Medicare paid $42,400 to providers for her care

(not including medications)


Chronic care is:

Fragmented

Discontinuous

Difficult to access

Inefficient

Unsafe

Expensive


The ¼ of Beneficiaries Who Have 4+ Chronic Conditions Account for 80% of Medicare Spending

Source: Medicare 5% Sample, 2001


Goals

Create a model that improves quality of care and reduces costs

Make the model diffusable throughout the United States


The Guided Care Model

Specially trained RNs based in primary physicians’ offices

GCNs collaborate with physicians in caring for 50-60 high-risk older patients with chronic conditions and complex health care needs


Nurse/physician team

Assesses needs and preferences

Creates an evidence-based “care guide” and a patient-friendly “action plan”

Monitors the patient proactively

Supports chronic disease self-management

Smoothes transitions between caresites

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


Linking with Community Resources

  • Data base of local community resources

  • Facilitate access to appropriate services

    • Empowerment

    • Paternalism

  • Meals on Wheels, senior centers, AAA, transportation programs, adult day care, CDSMP, social workers, pharmacists

  • GCN support groups  community support groups


Health System

Health Care Organization

ClinicalInformationSystems

Electronic Health Record, Care Guide,

Transitional Care, Coordination

Community

Resources and

Policies

Accessing

Self-Management Support

Chronic Disease Self-Management

DeliverySystem

Design

Guided Care Nurse

Decision

Support

Lexi-comp,

Evidence-based guidelines

Prepared,

Proactive

Practice Team

Monitoring

Coaching

Informed,

Activated

Patient

Chronic Disease Self-Management,

Caregiver Support,

Action Plan

Productive

Interactions

Improved Outcomes


Who is Eligible?

All

Patients

Age 65+

25%

High-Risk

75%

Low-Risk

Review previous year’s claims data with HCC software


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


Baseline Characteristics


Effects on Physician Satisfaction


Very Satisfied

Satisfied

Somewhat Satisfied

Somewhat Dissatisfied

Dissatisfied

Very Dissatisfied

Satisfaction Items

1= Familiarity with patients

2= Stability of patient relationships

3= Comm. w/ patients; Availability of clinical info; continuity of care for patients

4= Efficiency of office visits; access to evidence based guidelines

5= Monitoring patients; communicating w/ caregivers; efficiency of primary care team

6= Coordinating care; referring to community resources; educating caregivers

7= Motivating patients for self management


Effects on Quality of Care

* Adjusted for baseline socio-demographics, health, function, PACIC scores, site


Effects on Caregiver Strain


Annual Costs of Guided Care


Effects on Costs of Care(per caseload, 55 patients)


Early Results

  • Guided Care improves the quality of chronic care.

  • Guided Care reduces net expenditures for health care.

  • Guided Care is easy to implement and popular with physicians, nurses, patients and caregivers.


Future Directions

National pilot test involving Guided Care medical homes

Technical assistance

  • Book

  • Online course and certificate for nurses

  • Online course for physicians

  • Guidance in selecting HIT

  • Learning collaboratives and communities

  • Consultation


Grant Support

Agency for Healthcare Research and Quality

National Institute on Aging

John A. Hartford Foundation

Jacob and Valeria Langeloth Foundation


Publications

Boyd C et al. Gerontologist Nov 2007

Sylvia M et al. Dis Manag Feb 2008

Boyd C et al. J Gen Intern Med Feb 2008

Boult C et al. J Gerontology Mar 2008

Wolff et al. J Gerontology June 2009

Leff B et al. Am J Managed Care August 2009

“Guided Care: a New Nurse-Physician Partnership for Chronic Care.” Springer Publishing Co. 2009

(www.springerpub.com/guidedcare)

http://www.guidedcare.org


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