A Matched-Pair Cluster-Randomized Trial of Guided Care for High-Risk Older Patients

Abstract

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.

Home-based health promotion for older people with mild frailty: the HomeHealth intervention development and feasibility RCT

“…We included 19 studies of people who were frail or at risk of frailty: 16 RCTs, 12,13,[56][57][58][59][60][61][62][63][64][65][66][67][68][69] two clusters RCTs 48,70 and one pseudocluster RCT 71 (see Report Supplementary Material 3 for study characteristics). Most (n = 16) compared one intervention to control, with three three-arm trials.…”

“…The effects of changing health behaviours to prevent frailty are mixed, 12,48 which could arise from ineffectiveness in achieving behaviour change or the ineffectiveness of the behaviour change upon the outcome. Health behaviours can be defined as activities that may contribute to disease prevention, disease or disability detection, health promotion or protection from risk of injury.…”

“…48,63,64 Most interventions (n = 11/22) targeted a single behaviour, 12,[61][62][63][64][66][67][68]70,71 while nine targeted two or three behaviours 13,[56][57][58][59]65,69 and two targeted four or more behaviours. 48, 60 The behaviours most commonly targeted were medication adherence or management (n = 16), 13,48,56,[58][59][60][61][63][64][65][66]68,69 physical activity (n = 11) 12,13,48,56,57,59,60,65,70 and diet (n = 8), 13,48,56,57,60,69...…”

Decreasing Heart Failure Revisits

“…Interventions can be singular or bundled, involve actions by one health care provider or multidisciplinary providers, be short or long term in duration, and be focused on the hospital, the community or start in the hospital and continue into the community (see supplement) [24][25][26][27]. Although frequently used, there was marked heterogeneity in published programs and strategies, making it difficult to identify what really worked (see supplement legend, which contains hospital-to-home transitional care program websites that provide interventional components and other details of transitional care used clinically or in clinical research).…”

Effects of Guided Care on Providers' Satisfaction with Care: A Three-Year Matched-Pair Cluster-Randomized Trial

“…29 Publications from this trial have shown that Guided Care improves patient-reported quality of chronic health care as measured by the Patient Assessment of Chronic Illness Care (PACIC) and the Primary Care Assessment Survey. [29][30][31] Family caregivers' perceptions of the quality of the chronic illness care, measured by PACIC, were improved as well. 32 Preliminary results indicated that Guided Care may be associated with less use of expensive health services (ie, hospital, skilled nursing facility, emergency department, home care services).…”