The Effects of Guided Care on the Perceived Quality of Health Care for Multi-morbid Older Persons: 18-Month Outcomes from a Cluster-Randomized Controlled Trial
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The quality of health care for older Americans with chronic conditions is suboptimal.
To evaluate the effects of “Guided Care” on patient-reported quality of chronic illness care.
Cluster-randomized controlled trial of Guided Care in 14 primary care teams.
Older patients of these teams were eligible to participate if, based on analysis of their recent insurance claims, they were at risk for incurring high health-care costs during the coming year. Small teams of physicians and their at-risk older patients were randomized to receive either Guided Care (GC) or usual care (UC).
“Guided Care” is designed to enhance the quality of health care by integrating a registered nurse, trained in chronic care, into a primary care practice to work with 2–5 physicians in providing comprehensive chronic care to 50–60 multi-morbid older patients.
Eighteen months after baseline, interviewers blinded to group assignment administered the Patient Assessment of Chronic Illness Care (PACIC) survey by telephone. Logistic and linear regression was used to evaluate the effect of the intervention on patient-reported quality of chronic illness care.
Of the 13,534 older patients screened, 2,391 (17.7%) were eligible to participate in the study, of which 904 (37.8%) gave informed consent and were cluster-randomized. After 18 months, 95.3% and 92.2% of the GC and UC recipients who remained alive and eligible completed interviews. Compared to UC recipients, GC recipients had twice greater odds of rating their chronic care highly (aOR = 2.13, 95% CI = 1.30–3.50, p = 0.003).
Guided Care improves self-reported quality of chronic health care for multi-morbid older persons.
KEY WORDSquality of care chronic illness older
Supported by the John A. Hartford Foundation, the Agency for Healthcare Research and Quality, the National Institute on Aging, the Jacob and Valeria Langeloth Foundation, Kaiser-Permanente Mid-Atlantic States, Johns Hopkins HealthCare, and the Roger C. Lipitz Center for Integrated Health Care.
The authors acknowledge the invaluable contributions to this study made by Johns Hopkins Community Physicians, MedStar Physician Partners, Battelle Centers for Public Health Research, the Centers for Medicare & Medicaid Services, Accumen, ResDAC, the University of Minnesota Survey Research Center, the study consultants (Jean Giddens, RN, PhD; Kate Lorig, RN, DrPH; Richard Bohmer, MD, MPH, MBA; and Mary Naylor, RN, PhD), the nurse managers (Lora Rosenthal, RN, and Carol Groves, RN, MPA), data analysts (Martha Sylvia, RN, MSN, MBA, and Paula Norman, BS), administrative assistant (Adriane King, MA), and all of the participating patients, caregivers, physicians, and Guided Care nurses.
Conflict of Interest
Dr. Boyd received an honorarium for speaking on multimorbidity at a conference jointly sponsored by AHRQ, Center for HealthCare Strategies, and Schaller Anderson in 2006. Ms. Frey received an honorarium for speaking at a conference in Spain on multidisciplinary heart failure programs sponsored by the Grupo Menarini. Dr. Marsteller has stock and stock options in Freddie Mac (husband’s employer). Dr. Karm is employed by the Mid-Atlantic Permanente Group (for profit), which is the exclusive partner of Kaiser Permanente (not for profit). Ms. Groves is employed by the not-for-profit Kaiser Health Plan, which has an exclusive contract with the Mid-Atlantic Permanente Group.
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