Abstract
Background: ‘Guided Care’ (GC) is primary care into which several successful innovations in chronic care have been translated, in accord with the ‘chronic care model.’ This study examines the effect of GC on the quality of medically complex older adults’ health care. A registered nurse based in a primary care practice and supported by a web-accessible, evidence-based electronic health record, works closely with 2–4 physicians in caring for 50–60 of their multi-morbid older patients. For each patient the nurse performs a comprehensive assessment at home and then collaborates with the physician, the patient and the caregiver to customize an evidence-based ‘Care Guide’ for healthcare professionals and a personal health ‘Action Plan’ for the patient and caregiver. Thereafter, the nurse monitors the patient’s chronic conditions proactively, coaches the patient in self-management, smoothes transitions between settings of care, coordinates multiple providers, educates and supports caregivers, and facilitates access to community resources.
Methods: Using claims-based predictive modeling, we identified the top 25% chronically ill older patients at highest risk for health care utilization in the subsequent year within three Kaiser Permanente practices. A total of six primary care teams representing 20 primary care physicians and 403 of their patients consented to participate in the trial of which three teams were randomized to receive a GC nurse. We assessed quality of care after 6 months using the Patient Assessment of Chronic Illness Care (PACIC), an instrument which measures self-reported quality of care in five domains.
Results: Eighty-six percent of GC patients (n=204) and controls (n=199) responded to baseline and follow-up interviews. Patients receiving GC were two times more likely to rate the quality of their care as ‘highest quality’ compared to patients in the control group after adjusting for baseline sociodemographic characteristics, health status, functional ability, practice site, satisfaction with healthcare and PACIC score (OR, 1.99, P=0.054). GC patients had a significantly higher rating of care within the following domains: goal setting (OR, 2.55, P=0.003), coordination of care (OR, 3.09, P=0.006), and decision support (OR, 1.73, P=0.026).
Conclusion: Preliminary results suggest GC improves the quality of care for complex, chronically ill older adults.
- Received September 11, 2008.
