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Background The effect of interdisciplinary primary care teams on the use of health services by patients with multiple chronic conditions is uncertain. This study aimed to measure the effect of guided care teams on multimorbid older patients’ use of health services. Methods Eligible patients from 3 health care systems in the Baltimore, Maryland–Washington, DC, area were cluster-randomized to receive guided care or usual care for 20 months between November 1, 2006, and June 30, 2008. Eight services of a guided care nurse working in partnership with patients’ primary care physicians were provided: comprehensive assessment, evidence-based care planning, monthly monitoring of symptoms and adherence, transitional care, coordination of health care professionals, support for self-management, support for family caregivers, and enhanced access to community services. Outcome measures were frequency of use of emergency departments, hospitals, skilled nursing facilities, home health agencies, primary care physician services, and specialty physician services. Results The study included 850 older patients at high risk for using health care heavily in the future. The only statistically significant overall effect of guided care in the whole sample was a reduction in episodes of home health care (odds ratio, 0.70; 95% confidence interval, 0.53–0.93). In a preplanned analysis, guided care also reduced skilled nursing facility admissions (odds ratio, 0.53; 95% confidence interval,0.31–0.89) and days (0.48; 0.28–0.84) among Kaiser-Permanente patients. Conclusions Guided care reduces the use of home health care but has little effect on the use of other health services in the short run. Its positive effect on Kaiser-Permanente patients’ use of skilled nursing facilities and other health services is intriguing. Trial Registration clinicaltrials.gov Identifier: NCT00121940

Purpose: The purpose of this study was to test the feasibility of a new model of health care designed to improve the quality of life and the efficiency of resource use for older adults with multimorbidity. Design and Methods: Guided Care enhances primary care by infusing the operative principles of seven chronic care innovations: disease management, self-management, case management, lifestyle modification, transitional care, caregiver education and support, and geriatric evaluation and management. To practice Guided Care, a registered nurse completes an educational program and uses a customized electronic health record in working with two to five primary care physicians to meet the health care needs of 50 to 60 older patients with multimorbidity. For each patient, the nurse performs a standardized comprehensive home assessment and then collaborates with the physician, the patient, and the caregiver to create two comprehensive, evidencebased management plans: a Care Guide for health care professionals, and an Action Plan for the patient and caregiver. Based in the primary care office, the nurse then regularly monitors the patient's chronic conditions, coaches the patient in self-management, coordinates the efforts of all involved health care professionals, smoothes the patient's transitions between sites of care, provides education and support for family caregivers, and facilitates access to community resources. -Results: A 1-year pilot test in a community-based primary care practice suggested that Guided Care is feasible and acceptable to physicians, patients, and caregivers. Implications: If successful in a controlled trial, Guided Care could improve the quality of life and efficiency of health care for older adults with multimorbidity.

Although the etiology of chronic pain following trauma is not well understood, numerous retrospective studies have shown that a significant proportion of chronic pain patients have a history of traumatic injury. The present analysis examines the prevalence and early predictors of chronic pain in a cohort of prospectively followed severe lower extremity trauma patients. Chronic pain was measured using the Graded Chronic Pain Scale, which measures both pain severity and pain interference with activities. Severe lower extremity trauma patients report significantly higher levels of chronic pain than the general population (p<0.001). Their levels are comparable to primary care migraine headache and back pain populations. A number of early predictors of chronic pain were identified, including: having less than a high school education (p<0.01), having less than a college education (p<0.001), low self-efficacy for return to usual major activities (p<0.01), and high levels of average alcohol consumption at baseline (p<0.05). In addition, high reported pain intensity, high levels of sleep and rest dysfunction, and elevated levels of depression and anxiety at 3 months post-discharge were also strong predictors of chronic pain at seven years (p<0.001 for all three predictors). After adjusting for early pain intensity, patients treated with narcotic medication during the first 3 months post-discharge had lower levels of chronic pain at 84 months. It is possible that for patients within these high risk categories, early referral to pain management and/or psychologic intervention may reduce the likelihood or severity of chronic pain.

GC improves important aspects of the quality of health care for multimorbid older persons. Additional data will become available as this trial continues.

Objectives The Patient Activation Measure (PAM) quantifies the extent to which people are informed about and involved in their health care. Objectives were to determine the psychometric properties of PAM among multi-morbid older adults and evaluate a theoretical, four-stage model of patient activation. Methods A cross-sectional analysis was used to assess the psychometric properties of PAM. Internal consistency was assessed using Cronbach’s alpha. Construct validity was evaluated using general linear modeling to compute associations between PAM scores and health-related behaviors, functional status and health care quality. Latent class analysis was used to evaluate the theoretical four-stage structure of patient activation. Study Setting Participants in a randomized trial of Guided Care (N = 855), a model of comprehensive health care for older adults with chronic conditions that put them at risk of using health services heavily during the coming year. Principal Findings Higher PAM activation scores and stage were positively associated with higher functional status, health care quality, and adherence to some health behaviors. Latent class analysis supported the multi-stage theory of patient activation. Conclusions The PAM is a reliable, valid, and potentially clinically useful measure of patient activation for multi-morbid older adults.

The purpose of this study was to determine the efficacy of a cognitive-behavioral based physical therapy (CBPT) program for improving outcomes in patients following lumbar spine surgery. A randomized controlled trial was conducted in 86 adults undergoing a laminectomy with or without arthrodesis for a lumbar degenerative condition. Patients were screened preoperatively for high fear of movement using the Tampa Scale for Kinesiophobia. Randomization to either CBPT or an Education program occurred at 6 weeks after surgery. Assessments were completed pre-treatment, post-treatment and at 3 month follow-up. The primary outcomes were pain and disability measured by the Brief Pain Inventory and Oswestry Disability Index. Secondary outcomes included general health (SF-12) and performance-based tests (5-Chair Stand, Timed Up and Go, 10 Meter Walk). Multivariable linear regression analyses found that CBPT participants had significantly greater decreases in pain and disability and increases in general health and physical performance compared to the Education group at 3 month follow-up. Results suggest a targeted CBPT program may result in significant and clinically meaningful improvement in postoperative outcomes. CBPT has the potential to be an evidence-based program that clinicians can recommend for patients at-risk for poor recovery following spine surgery.

BACKGROUND: Patients at risk for generating high health care expenditures often receive fragmented, lowquality, inefficient health care. Guided Care is designed to provide proactive, coordinated, comprehensive care for such patients. OBJECTIVE: We hypothesized that Guided Care, compared to usual care, produces better functional health and quality of care, while reducing the use of expensive health services. DESIGN: 32-month, single-blind, matched-pair, cluster-randomized controlled trial of Guided Care, conducted in eight community-based primary care practices. PATIENTS: The "Hierarchical Condition Category" (HCC) predictive model was used to identify high-risk older patients who were insured by fee-for-service Medicare, a Medicare Advantage plan or Tricare. Patients with HCC scores in the highest quartile (at risk for generating high health care expenditures during the coming year) were eligible to participate. INTERVENTION: A registered nurse collaborated with two to five primary care physicians in providing eight services to participants: comprehensive assessment, evidence-based care planning, proactive monitoring, care coordination, transitional care, coaching for selfmanagement, caregiver support, and access to community-based services. MAIN MEASURES: Functional health was measured using the Short Form-36. Quality of care and health services utilization were measured using the Patient Assessment of Chronic Illness Care and health insurance claims, respectively. KEY RESULTS: Of the eligible patients, 904 (37.8 %) gave written consent to participate; of these, 477 (52.8 %) completed the final interview, and 848 (93.8 %) provided complete claims data. In intention-to-treat analyses, Guided Care did not significantly improve participants' functional health, but it was associated with significantly higher participant ratings of the quality of care (difference=0.27, 95 % CI=0.08-0.45) and 29 % lower use of home care (95 % CI=3-48 %). CONCLUSIONS: Guided Care improves high-risk older patients' ratings of the quality of their care, and it reduces their use of home care, but it does not appear to improve their functional health.