Linking Clinical Practice and Community Resources: The Guided Care Model

Slide presentation from the AHRQ 2009 conference.

On September 14, 2009, Chad Boult made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (626 KB) (Plugin Software Help).

Slide 1

Slide 1. Linking Clinical Practice and Community Resources: The Guided Care Model
 

Linking Clinical Practice and
Community Resources:

The Guided Care Model

Chad Boult, MD, MPH, MBA
Professor of Public Health, Medicine and Nursing
Johns Hopkins University


AHRQ 2009 Annual Conference
September 14, 2009

Slide 2

Slide 2. Ms. Marian Chen
 

Ms. Marian Chen

  • 79 year old widow
  • Retired teacher, lives alone
  • Income: SS, pension and Medicare
  • Daughter, lives 10 miles away with three teenagers
  • Five chronic conditions
  • Three physicians
  • Eight medications

 

Slide 3

Slide 3. In 2009, Mrs. Chen has had . . .
 

In 2009, Mrs. Chen has had...

 

Slide 4

Slide 4. Mrs. Chen and Her Daughter
  • Mrs. Chen
    • Confused by care, meds
    • Poor quality of life
    • High out-of-pocket costs
  • Daughter
    • Stressed out
    • Reduced work to half-time
    • Considering nursing homes

Medicare paid $42,400 to providers for her care
(not including medications)
 

 

Slide 5

Slide 5. Chronic care is: 
 

Chronic care is:

  • Fragmented
  • Discontinuous
  • Difficult to access
  • Inefficient
  • Unsafe
  • Expensive

 

Slide 6

Slide 6. The ¼ of Beneficiaries Who Have 4+ Chronic Conditions Account for 80% of Medicare Spending
Source: Medicare 5% Sample, 2001
The 1/4 of Beneficiaries Who Have 4+ Chronic Conditions Account for 80% of Medicare Spending
 

 

Slide 7

Slide 7. Goals 
 

Goals

  • Create a model that improves quality of care and reduces costs
  • Make the model diffusable throughout the United States

 

Slide 8

Slide 8. The Guided Care Model
 

The Guided Care Model

  • Specially trained RNs based in primary physicians' offices
  • GCNs collaborate with physicians in caring for 50-60 high-risk older patients with chronic conditions and complex health care needs

 

Slide 9

Slide 9. Nurse/Physician Team
 

Nurse/physician team

  • Assesses needs and preferences
  • Creates an evidence-based "care guide" and a patient-friendly "action plan"
  • Monitors the patient proactively
  • Supports chronic disease self-management
  • Smoothes transitions between care sites
  • Communicates with providers in EDs, hospitals, specialty clinics, rehab facilities, home care agencies, hospice programs, and social service agencies in the community
  • Educates and supports caregivers
  • Facilitates access to community services

 

Slide 10

Slide 10. Linking with Community Resources
 

Linking with Community Resources

  • Data base of local community resources
  • Facilitate access to appropriate services
    • Empowerment
    • Paternalism
  • Meals on Wheels, senior centers, AAA, transportation programs, adult day care, CDSMP, social workers, pharmacists
  • GCN support groups? community support groups

 

Slide 11

Slide 11. Image about improved outcomes
 

[Image about improved outcomes]

 

Slide 12

Slide 12. Who is Eligible?
 

Who is Eligible?



All
Patients
Age 65+


25%
High-Risk
75%
Low-Risk
Review previous year's claims data with HCC software
 

 

Slide 13

Slide 13. Randomized Trial
 

Randomized Trial

  • High-risk older patients (n=904) of 49 community-based primary care physicians practicing in 14 teams
  • Physician/patient teams randomly assigned to receive Guided Care or "usual" care
  • Outcomes measured at 8, 20 and 32 months

 

Slide 14

Slide 14. Baseline Characteristics
 

Baseline Characteristics

 

Slide 15

Slide 15. Effects on Physician Satisfaction
 

Effects on Physician Satisfaction

 

Slide 16

Slide 16. GCN's Satisfaction with Clinical Activities (Graph)
Very Satisfied
Very Dissatisfied
Satisfaction Items
1= Familiarity with patients
2= Stability of patient relationships
3= Comm. w/ patients; Availability of clinical info; continuity of care for patients
4= Efficiency of office visits; access to evidence based guidelines
5= Monitoring patients; communicating w/ caregivers; efficiency of primary care team
6= Coordinating care; referring to community resources; educating caregivers
7= Motivating patients for self management
Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Dissatisfied
 

 

Slide 17

Slide 17. Effects on Quality of Care 
 

Effects on Quality of Care

* Adjusted for baseline socio-demographics, health, function, PACIC scores, site
 

 

Slide 18

Slide 18. Effects on Caregiver Strain
 

Effects on Caregiver Strain

 

Slide 19

Slide 19. Annual Costs of Guided Care
 

Annual Costs of Guided Care

 

Slide 20

Slide 20. Effects on Costs of Care (per caseload, 55 patients)
 

Effects on Costs of Care
(per caseload, 55 patients)

 

Slide 21

Slide 21. Early Results
 

Early Results

  • Guided Care improves the quality of chronic care.
  • Guided Care reduces net expenditures for health care.
  • Guided Care is easy to implement and popular with physicians, nurses, patients and caregivers.

 

Slide 22

Slide 22. Future Directions
 

Future Directions

  • National pilot test involving Guided Care medical homes
  • Technical assistance
    • Book
    • Online course and certificate for nurses
    • Online course for physicians
    • Guidance in selecting HIT
    • Learning collaboratives and communities
    • Consultation

 

Slide 23

Slide 23. Grant Support
 

Grant Support

  • Agency for Healthcare Research and Quality
  • National Institute on Aging
  • John A. Hartford Foundation
  • Jacob and Valeria Langeloth Foundation

 

Slide 24

Slide 24. Publications
 

Publications

  • Boyd C et al. Gerontologist Nov 2007
  • Sylvia M et al. Dis Manag Feb 2008
  • Boyd C et al. J Gen Intern Med Feb 2008
  • Boult C et al. J Gerontology Mar 2008
  • Wolff et al. J Gerontology June 2009
  • Leff B et al. Am J Managed Care August 2009
  • "Guided Care: a New Nurse-Physician Partnership for Chronic Care." Springer Publishing Co. 2009
  • (www.springerpub.com/guidedcare)
  • wwwguidedcare.org
Current as of December 2009
Internet Citation: Linking Clinical Practice and Community Resources: The Guided Care Model. December 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2009/boult/index.html