Original Article

Journal of General Internal Medicine

, Volume 23, Issue 5, pp 536-542

A Pilot Test of the Effect of Guided Care on the Quality of Primary Care Experiences for Multimorbid Older Adults

  • Cynthia M. BoydAffiliated withDivision of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of MedicineRoger C. Lipitz Center for Integrated Health Care, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health Email author 
  • , Efrat ShadmiAffiliated withThe Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa
  • , Leslie Jackson ConwellAffiliated withRoger C. Lipitz Center for Integrated Health Care, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
  • , Michael GriswoldAffiliated withDepartment of Biostatistics, Johns Hopkins Bloomberg School of Public Health
  • , Bruce LeffAffiliated withDivision of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of MedicineRoger C. Lipitz Center for Integrated Health Care, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
  • , Rosemarie BragerAffiliated withJohns Hopkins University School of Nursing
  • , Martha SylviaAffiliated withJohns Hopkins HealthCare
  • , Chad BoultAffiliated withDivision of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of MedicineRoger C. Lipitz Center for Integrated Health Care, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health

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Abstract

Objective

Improving health care of multimorbid older adults is a critical public health challenge. The objective of this study is to evaluate the effect of a pilot intervention to enhance the quality of primary care experiences for chronically ill older persons (Guided Care).

Design

Nonrandomized prospective clinical trial.

Patients/Participants

Older, chronically ill, community-dwelling patients (N = 150) of 4 General Internists in 1 urban community practice setting who were members of a capitated health plan and identified as being at high risk of heavy use of health services in the coming year by claims-based predictive modeling.

Interventions

Guided Care, an enhancement to primary care that incorporates the operative principles of chronic care innovations, was delivered by a specially trained, practice-based registered nurse working closely with 2 primary care physicians. Each patient received a geriatric assessment, a comprehensive care plan, evidence-based primary care with proactive follow-up of chronic conditions, coordination of the efforts of health professionals across all health care settings, and facilitated access to community resources.

Measurements and Main Results

Quality of primary care experiences (physician–patient communication, interpersonal treatment, knowledge of patient, integration of care, and trust in physician) was assessed using the Primary Care Assessment Survey (PCAS) at baseline and 6 months later. At baseline, the patients assigned to receive Guided Care were similar to those assigned to receive usual care in their demographics and disability levels, but they had higher risk scores and were less likely to be married. Thirty-one of the 75 subjects assigned to the Guided Care group received the intervention. At 6 months, intention-to-treat analyses adjusting for age, gender, and risk score suggest that Guided Care may improve the quality of physician–patient communication. In per-protocol analyses, receipt of Guided Care was associated with more favorable change than usual care from baseline to follow-up in all 5 PCAS domains, but only physician–patient communication showed a statistically significant improvement.

Conclusions

In this pilot study, Guided Care appeared to improve the quality of primary care experiences for high-risk, chronically ill older adults. A larger cluster-randomized controlled trial of Guided Care is underway.

KEY WORDS

aged multimorbidity chronic disease nursing quality of care