Research Activities, February 2014
New model of primary care for patients with multiple chronic conditions shows mixed results
For patients with two or more chronic conditions, health care is often fragmented, low quality, inefficient, and unsatisfactory to them and their clinicians. These patients are also at high risk of generating high health care expenditures. A 32-month test of Guided Care, a new model of comprehensive interdisciplinary care for patients with multiple chronic conditions, did not significantly improve primary care patients' functional health, but it was associated with higher patient ratings of the quality of care. Also, access to telephone advice improved and patients' use of home health care declined.
Participating in the test were 904 high-risk older patients in 8 primary care practices. The Guided Care model of comprehensive interdisciplinary care comprises primary care-based care management, transitional care, and support for self-management and family caregiving. In Guided Care, a registered nurse works with 2 to 5 physicians in a primary care practice to provide 50-60 high-risk, multi-morbid patients with eight services: home-based assessment of patients' needs and goals, evidence-based care planning, proactive monitoring, care coordination, transitional care, coaching for self-management, caregiver support, and access to community-based services.
The researchers suggest that several factors may underlie the observed lack of significant effect on patients' functional health and use of some health services:
- Inadequate potency of the initial version of Guided Care.
- The considerable heterogeneity in the implementation of the model by the individual nurses and physicians in the 7 different intervention teams.
- Inadequate statistical power to draw inferences about the intervention's effects on health care use.
The potential for Guided Care to control the use and costs of health care remains uncertain. The authors note that the significant savings from reductions in the use of home health care would help to offset the costs of the intervention. However, concomitant reductions in the use of hospitals and skilled nursing facilities would probably be necessary for the model to show cost neutrality or reduce high-risk patients' net health care costs. This study was supported by AHRQ (HS14580).
See "A matched-pair cluster-randomized trial of guided care for high-risk older patients," by Chad Boult, M.D., Bruce Leff, M.D., Cynthia M. Boyd, M.D., and others in Journal of General Internal Medicine 28(5), pp. 612-621, 2013.