Guided care reduces the use of health services by chronically ill older adults

A new report shows that older people who receive Guided Care, a new form of primary care, use fewer expensive health services compared to older people who receive regular primary care. Research published in the March 2011 edition of Archives of Internal Medicine found that after 20 months of a randomized controlled trial, Guided Care patients experienced, on average, 30 percent fewer home health care episodes, 21 percent fewer hospital readmissions, 16 percent fewer skilled nursing facility days, and 8 percent fewer skilled nursing facility admissions. Only the reduction in home health care episodes was statistically significant.

According to the study, Guided Care produced even larger reductions in a subset of patients who received their primary care from one well managed health system. Guided Care patients in Kaiser Permanente of the Mid Atlantic States experienced, on average, 52 percent fewer skilled nursing facility days, 47 percent fewer skilled nursing facility admissions, 49 percent fewer hospital readmissions, and 17 percent fewer emergency department visits; the differences for skilled nursing facility days and admissions were statistically significant.

"These data suggest that Guided Care can reduce avoidable health service use and costs in well managed systems," said lead author Chad Boult, MD, MPH, MBA. "Because they are part of a delivery system in which their health professionals already work as a team, Kaiser Permanente and similarly coordinated systems may be better able to achieve cost savings with a comprehensive, team-based care model such as Guided Care," said Boult. "We would like to further explore which elements of the Kaiser-Permanente culture may have helped Guided Care reduce the use of costly health services."

This multi-site, randomized controlled trial of Guided Care involving 49 physicians, 904 older patients and 319 family members recently concluded in 8 locations in the Baltimore-Washington, D.C. area. The three-year study was funded by a private-public partnership of the John A. Hartford Foundation, the Jacob and Valeria Langeloth Foundation, the Agency for Healthcare Research and Quality, and the National Institute on Aging.

Additional authors of "The Effect of Guided Care Teams of the Use of Health Services: Results from a Cluster-Randomized Controlled Trial" include Lisa Reider, MHS; Bruce Leff, MD; Kevin D. Frick, PhD; Cynthia M. Boyd, MD, MPH; Jennifer Wolff, PhD; Katherine Frey, MPH, RN, MS; Lya Karm, MD; Stephen T. Wegener, PhD; Tracy Mroz, MS, OTR/L; and Daniel O. Scharfstein, ScD.

Previous articles have reported that Guided Care patients and their family caregivers rate the quality of their health care more highly than other patients -- and that Guided Care improves physicians' satisfaction with the chronic care they provide.

Guided Care is a model of proactive, comprehensive health care provided by physician-nurse teams for people with several chronic health conditions. Primary care practices can adopt Guided Care to help become patient-centered medical homes or accountable care organizations. The model is designed to improve quality of care and quality of life, while improving the efficiency of treating the sickest and most complex patients. Guided Care teams consist of a registered nurse, two to five physicians, and the other members of the primary care office staff who work together for the benefit of each patient to:

• Assess the patient and family caregiver at home
  
• Create an evidence-based 'Care Guide' (care plan) and patient-friendly 'Action Plan'
  
• Monitor the patient's conditions monthly
  
• Promote patient self-management
  
• Coordinate the efforts of all the patient's healthcare providers
  
• Smooth the patient's transition between sites of care
  
• Inform and support family caregivers
  
• Facilitate access to community resources