Guided Care Boosts Knowledge of Patient Needs

CHICAGO — A primary care delivery model for older patients with multiple chronic illnesses increased physician understanding of the patients' clinical conditions and improved communication with patients and families, in a randomized trial at eight primary care practices.

The study findings, presented in a poster at the annual research meeting of AcademyHealth, add to a growing body of evidence that the model can improve outcomes, reduce costs, and enhance the quality of care for chronically ill older adults.

In the Guided Care model—an initiative developed by the Johns Hopkins Bloomberg School of Public Health, Baltimore—a Guided Care nurse works with three or four primary care physicians and a targeted population of 50-60 patients. The nurse receives additional training in patient education and coaching and in chronic disease management.

The nurse also develops a comprehensive care plan for each patient based on medical conditions, the home environment, and individual patient goals; monitors patients monthly; coordinates transitions between providers and sites of care; educates and supports caregivers; keeps an electronic health record; and provides physicians with detailed updates.

“Physicians don't have a lot of time to do these things for every one of their complex patients,” Jill Marsteller, Ph.D., noted in an interview. “The nurse helps very much in terms of having a close personal relationship with these people who are so complex, and can provide them with the guidance that they need to access community resources and help them keep track of all the different visits.” The nurse also summarizes the information for the physician, she said, and in so doing, “is really helping the primary care physician as a partner in the care of this patient.”

The nurse visits the patient's home when Guided Care begins, making a connection that can yield valuable insights that might not come out in a medical interview. The patient who reports difficulty sleeping, for example, may be found during the home visit to have a kitchen stocked with caffeinated soft drinks.

A randomized trial of Guided Care—one aspect of which was reported in the poster presented at the meeting—has shown that this heightened attention to patients and support for physicians improves outcomes and increases patient satisfaction with their care. In the trial, 49 primary care physicians at eight community-based medical practices in the Baltimore and Washington D.C. region and 904 of their patients aged 65 years or older with multiple comorbidities were randomly assigned to Guided Care or usual care. Although the patients chosen for the study had multiple chronic illnesses, the study did not include patients who were severely ill or near death.

After 6 months, patients receiving Guided Care were twice as likely as were patients receiving usual care to rate the quality of their care as high (J. Gerontol. A Biol. Sci. Med. Sci. 2008;63:321-7). Caregivers of Guided Care patients, particularly those who spent 14 or more hours weekly caring for a family member, reported less “strain” and depression than did caregivers of usual care patients (J. Gerontol. A Biol. Sci. Med. Sci. 2009; 64:785-91). After 8 months, Guided Care patients spent 24% fewer days in the hospital, and had 29% fewer home health visits and 15% fewer emergency department visits (Am. J. Manag. Care 2009; 15:555-9).

The most recent phase of the study, presented at the AcademyHealth meeting, focused on physician satisfaction and perceptions after participating in the project for 1 year.

“Compared to the physicians in the control group, the physicians in Guided Care rated their satisfaction with patient/family communication and their knowledge of their chronically ill patients' clinical conditions significantly higher,” Ms. Marsteller and her colleagues reported.

On a six-point scale ranging from “very dissatisfied” to “very satisfied,” physicians in the control group gave mean ratings of 4.25 and 3.94, at baseline and at 1 year, respectively, for satisfaction with patient/family communication, while physicians in the Guided Care group gave mean ratings of 4.03 and 4.40. On a four-point scale measuring clinical knowledge of patients, with responses ranging from “definitely not” to “definitely,” physicians in the control group gave mean ratings of 2.70 and 2.77 at baseline and 1 year, respectively, while physicians in the Guided Care group gave mean ratings of 2.85 and 3.17.

Although the physicians who participated in the Guided Care group also reported greater satisfaction than did those in the usual care group on other measures, differences between the two groups did not reach statistical significance on these dimensions, which included satisfaction with management of chronic care and care coordination activities, time spent managing patients, personal knowledge of patients, and written information sent to specialists. The lack of significant results in these dimensions probably reflects the limited number of physicians who participated in the study. “We expect that after 2 and 3 years, we will begin to see a stronger effect,” said Ms. Marsteller of Johns Hopkins University's Bloomberg School of Public Health.

The study was funded by the John A. Hartford Foundation and the Roger C. Lipitz Center for Integrated Health Care of the Bloomberg School of Public Health.

The main study, of which this study is a part, also received support from the Agency for Healthcare Research and Quality, the National Institute on Aging, the Jacob and Valeria Langeloth Foundation, Kaiser-Permanente Mid-Atlantic, and Johns Hopkins Health Care.

More information about Guided Care is available at www.guidedcare.org

CHICAGO — A primary care delivery model for older patients with multiple chronic illnesses increased physician understanding of the patients' clinical conditions and improved communication with patients and families, in a randomized trial at eight primary care practices.

The study findings, presented in a poster at the annual research meeting of AcademyHealth, add to a growing body of evidence that the model can improve outcomes, reduce costs, and enhance the quality of care for chronically ill older adults.

In the Guided Care model—an initiative developed by the Johns Hopkins Bloomberg School of Public Health, Baltimore—a Guided Care nurse works with three or four primary care physicians and a targeted population of 50-60 patients. The nurse receives additional training in patient education and coaching and in chronic disease management.

The nurse also develops a comprehensive care plan for each patient based on medical conditions, the home environment, and individual patient goals; monitors patients monthly; coordinates transitions between providers and sites of care; educates and supports caregivers; keeps an electronic health record; and provides physicians with detailed updates.

“Physicians don't have a lot of time to do these things for every one of their complex patients,” Jill Marsteller, Ph.D., noted in an interview. “The nurse helps very much in terms of having a close personal relationship with these people who are so complex, and can provide them with the guidance that they need to access community resources and help them keep track of all the different visits.” The nurse also summarizes the information for the physician, she said, and in so doing, “is really helping the primary care physician as a partner in the care of this patient.”

The nurse visits the patient's home when Guided Care begins, making a connection that can yield valuable insights that might not come out in a medical interview. The patient who reports difficulty sleeping, for example, may be found during the home visit to have a kitchen stocked with caffeinated soft drinks.

A randomized trial of Guided Care—one aspect of which was reported in the poster presented at the meeting—has shown that this heightened attention to patients and support for physicians improves outcomes and increases patient satisfaction with their care. In the trial, 49 primary care physicians at eight community-based medical practices in the Baltimore and Washington D.C. region and 904 of their patients aged 65 years or older with multiple comorbidities were randomly assigned to Guided Care or usual care. Although the patients chosen for the study had multiple chronic illnesses, the study did not include patients who were severely ill or near death.

After 6 months, patients receiving Guided Care were twice as likely as were patients receiving usual care to rate the quality of their care as high (J. Gerontol. A Biol. Sci. Med. Sci. 2008;63:321-7). Caregivers of Guided Care patients, particularly those who spent 14 or more hours weekly caring for a family member, reported less “strain” and depression than did caregivers of usual care patients (J. Gerontol. A Biol. Sci. Med. Sci. 2009; 64:785-91). After 8 months, Guided Care patients spent 24% fewer days in the hospital, and had 29% fewer home health visits and 15% fewer emergency department visits (Am. J. Manag. Care 2009; 15:555-9).

The most recent phase of the study, presented at the AcademyHealth meeting, focused on physician satisfaction and perceptions after participating in the project for 1 year.

“Compared to the physicians in the control group, the physicians in Guided Care rated their satisfaction with patient/family communication and their knowledge of their chronically ill patients' clinical conditions significantly higher,” Ms. Marsteller and her colleagues reported.

On a six-point scale ranging from “very dissatisfied” to “very satisfied,” physicians in the control group gave mean ratings of 4.25 and 3.94, at baseline and at 1 year, respectively, for satisfaction with patient/family communication, while physicians in the Guided Care group gave mean ratings of 4.03 and 4.40. On a four-point scale measuring clinical knowledge of patients, with responses ranging from “definitely not” to “definitely,” physicians in the control group gave mean ratings of 2.70 and 2.77 at baseline and 1 year, respectively, while physicians in the Guided Care group gave mean ratings of 2.85 and 3.17.

Although the physicians who participated in the Guided Care group also reported greater satisfaction than did those in the usual care group on other measures, differences between the two groups did not reach statistical significance on these dimensions, which included satisfaction with management of chronic care and care coordination activities, time spent managing patients, personal knowledge of patients, and written information sent to specialists. The lack of significant results in these dimensions probably reflects the limited number of physicians who participated in the study. “We expect that after 2 and 3 years, we will begin to see a stronger effect,” said Ms. Marsteller of Johns Hopkins University's Bloomberg School of Public Health.

The study was funded by the John A. Hartford Foundation and the Roger C. Lipitz Center for Integrated Health Care of the Bloomberg School of Public Health.

The main study, of which this study is a part, also received support from the Agency for Healthcare Research and Quality, the National Institute on Aging, the Jacob and Valeria Langeloth Foundation, Kaiser-Permanente Mid-Atlantic, and Johns Hopkins Health Care.

More information about Guided Care is available at www.guidedcare.org

CHICAGO — A primary care delivery model for older patients with multiple chronic illnesses increased physician understanding of the patients' clinical conditions and improved communication with patients and families, in a randomized trial at eight primary care practices.

The study findings, presented in a poster at the annual research meeting of AcademyHealth, add to a growing body of evidence that the model can improve outcomes, reduce costs, and enhance the quality of care for chronically ill older adults.

In the Guided Care model—an initiative developed by the Johns Hopkins Bloomberg School of Public Health, Baltimore—a Guided Care nurse works with three or four primary care physicians and a targeted population of 50-60 patients. The nurse receives additional training in patient education and coaching and in chronic disease management.

The nurse also develops a comprehensive care plan for each patient based on medical conditions, the home environment, and individual patient goals; monitors patients monthly; coordinates transitions between providers and sites of care; educates and supports caregivers; keeps an electronic health record; and provides physicians with detailed updates.

“Physicians don't have a lot of time to do these things for every one of their complex patients,” Jill Marsteller, Ph.D., noted in an interview. “The nurse helps very much in terms of having a close personal relationship with these people who are so complex, and can provide them with the guidance that they need to access community resources and help them keep track of all the different visits.” The nurse also summarizes the information for the physician, she said, and in so doing, “is really helping the primary care physician as a partner in the care of this patient.”

The nurse visits the patient's home when Guided Care begins, making a connection that can yield valuable insights that might not come out in a medical interview. The patient who reports difficulty sleeping, for example, may be found during the home visit to have a kitchen stocked with caffeinated soft drinks.

A randomized trial of Guided Care—one aspect of which was reported in the poster presented at the meeting—has shown that this heightened attention to patients and support for physicians improves outcomes and increases patient satisfaction with their care. In the trial, 49 primary care physicians at eight community-based medical practices in the Baltimore and Washington D.C. region and 904 of their patients aged 65 years or older with multiple comorbidities were randomly assigned to Guided Care or usual care. Although the patients chosen for the study had multiple chronic illnesses, the study did not include patients who were severely ill or near death.

After 6 months, patients receiving Guided Care were twice as likely as were patients receiving usual care to rate the quality of their care as high (J. Gerontol. A Biol. Sci. Med. Sci. 2008;63:321-7). Caregivers of Guided Care patients, particularly those who spent 14 or more hours weekly caring for a family member, reported less “strain” and depression than did caregivers of usual care patients (J. Gerontol. A Biol. Sci. Med. Sci. 2009; 64:785-91). After 8 months, Guided Care patients spent 24% fewer days in the hospital, and had 29% fewer home health visits and 15% fewer emergency department visits (Am. J. Manag. Care 2009; 15:555-9).

The most recent phase of the study, presented at the AcademyHealth meeting, focused on physician satisfaction and perceptions after participating in the project for 1 year.

“Compared to the physicians in the control group, the physicians in Guided Care rated their satisfaction with patient/family communication and their knowledge of their chronically ill patients' clinical conditions significantly higher,” Ms. Marsteller and her colleagues reported.

On a six-point scale ranging from “very dissatisfied” to “very satisfied,” physicians in the control group gave mean ratings of 4.25 and 3.94, at baseline and at 1 year, respectively, for satisfaction with patient/family communication, while physicians in the Guided Care group gave mean ratings of 4.03 and 4.40. On a four-point scale measuring clinical knowledge of patients, with responses ranging from “definitely not” to “definitely,” physicians in the control group gave mean ratings of 2.70 and 2.77 at baseline and 1 year, respectively, while physicians in the Guided Care group gave mean ratings of 2.85 and 3.17.

Although the physicians who participated in the Guided Care group also reported greater satisfaction than did those in the usual care group on other measures, differences between the two groups did not reach statistical significance on these dimensions, which included satisfaction with management of chronic care and care coordination activities, time spent managing patients, personal knowledge of patients, and written information sent to specialists. The lack of significant results in these dimensions probably reflects the limited number of physicians who participated in the study. “We expect that after 2 and 3 years, we will begin to see a stronger effect,” said Ms. Marsteller of Johns Hopkins University's Bloomberg School of Public Health.

The study was funded by the John A. Hartford Foundation and the Roger C. Lipitz Center for Integrated Health Care of the Bloomberg School of Public Health.

The main study, of which this study is a part, also received support from the Agency for Healthcare Research and Quality, the National Institute on Aging, the Jacob and Valeria Langeloth Foundation, Kaiser-Permanente Mid-Atlantic, and Johns Hopkins Health Care.

More information about Guided Care is available at www.guidedcare.org