guided care: integrating high tech and high touch

Conditions: Chronic Disease

Summary: the purpose of the study is to evaluate the effect of a guided care nurse on the quality of the health and well-being of the frail elderly. a specially trained registered nurse will work closely with 1-3 primary care physicians to provide the most complex older patients (and their unpaid caregivers) with health care that is comprehensive, coordinated, patient-centered, and proactive. the study will evaluate the effects of guided care on: * older persons' physical and mental health, health services utilization, quality of care, self-efficacy, and satisfaction with care; * older persons' unpaid caregivers' burden; and * primary care physicians' satisfaction with their care of chronically ill patients.

health care for older americans with chronic conditions is often fragmented and provider-centric. in response, a team of investigators at johns hopkins university has translated the scientific principles of seven successful innovations into one patient-centered system of care. supported by evidence-based guidelines and state-of-the-art information technology, "guided care" is undergoing a 12-month pilot test in older primary care patients with complex needs. a specially trained guided care nurse (gcn), based in a primary care practice, collaborates with two primary care physicians to provide seven services for 40-60 high-risk patients: comprehensive assessment and care planning; "best practices" for chronic conditions; self-management; healthy lifestyles; coordinating care; educating and supporting unpaid caregivers; and accessing community resources. the proposed multi-site study will measure the effects of guided care on the quality and outcomes of care for high-risk older persons, their unpaid caregivers, and their primary care physicians. the panels of 53 physicians in 7 practices will be screened to identify 1350 high-risk older patients. after about 850 have given informed consent and baseline interviews, clusters of 2-5 physicians at each practice site will be randomized to provide either guided care or usual care to their consenting patients. each physician cluster in the guided care group will incorporate a gcn into its practice; the physician clusters in the control group will not. interviews and queries of administrative databases will provide evaluative data at baseline and at 12-, 24-, and 32-month follow-up intervals. the primary outcome variables are the participants' physical health and mental health (sf-36 summary scales) and health services utilization. secondary outcome variables include: the quality of care; unpaid caregivers' burden; self-rated health; patient satisfaction; and primary care physicians' satisfaction. intention-to-treat analyses will have 85% power (range of 70-97%) to detect clinically meaningful differences between the two groups. the study is designed to facilitate the prompt dissemination of guided care, if the results of the trial are favorable. a stakeholders' advisory board, representing consumers, providers, delivery systems, insurers, regulators and policy-makers, will inform the operation and evaluation of the study - and it will facilitate the subsequent dissemination of its tools and technology throughout american health care.

Eligibility criteria:
inclusion criteria: * over 65 * insured by kpmag, usfhp/tricare, or medicare ffs * high likelihood of use of services in the coming year based on predictive modeling using current year's health care expenses exclusion criteria: * moving out of area * currently assigned to case manager/in case management program * cognitive impairment and no legal representative

Keywords: chronic disease nurses caregivers support groups