“Guided Care” for People with Complex Health Care Needs

Abstract

Growing rapidly as the huge “baby boom” generation moves into retirement age is the population of people who have multiple chronic conditions that require complex arrays of services from multiple providers. Unfortunately, today’s complex health care is often chaotic, ineffective, inefficient, and poorly aligned with the preferences and needs of persons with complex health needs and their family caregivers.

“Guided care” is a pragmatic new model of health care that provides patient-centered, coordinated, comprehensive care to people who have complex health care needs. In this model, a specially educated registered nurse partners with two to five primary care physicians to provide eight personalized, longitudinal health care services to the physicians’ 50–60 most complex patients and their family caregivers. These services include patient and family caregiver assessment, care planning, promoting self-management, monitoring patients’ symptoms and adherence, coordinating health care providers, smoothing hospital transitions, supporting family caregivers, and accessing community-based services.

A 3-year, cluster-randomized pragmatic clinical trial (n = 904) in urban and suburban Baltimore and Washington, DC showed that, compared to recipients of “usual care,” recipients of guided care (all of whom had complex health care needs) were significantly:

• • More likely to rate their care as of high quality.

• • More likely to report “excellent or very good” access to telephone advice.

• • Less frequent users of home care services.

Guided care recipients were also more satisfied with the care they received from their primary care providers, and they had fewer hospital admissions (6 % reduction), 30-day hospital readmissions (13 % reduction), and skilled nursing facility days (26 % reduction), but these latter differences were not statistically significant.

Supported by online training for guided care nurses and physicians and a detailed implementation manual, guided care is now licensed for use by numerous US health care systems.