Guided Care for Multimorbid Older Adults

Boyd, Cynthia M.; Boult, Chad; Shadmi, Efrat; Leff, Bruce; Brager, Rosemarie; Dunbar, Linda; Wolff, Jennifer L.; Wegener, Stephen T.

doi:10.1093/geront/47.5.697

Cited by 179 publications

(204 citation statements)

References 45 publications

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“…It comprises elements of the Guided Care model that has shown to be feasible and acceptable for patients and caregivers (Boyd et al 2007). In contrast to interventions with a resource-based approach that aim to achieve and maintain overall well-being by stimulating self-management abilities (Steverink et al 2005), the current problem-oriented approach fits more closely to the available knowledge and expertise in general practices.…”

Section: Discussionmentioning

confidence: 99%

Development of a home visitation programme for the early detection of health problems in potentially frail community-dwelling older people by general practices

Stijnen

Jansen²,

Vrijhoef

et al. 2012

Eur J Ageing

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The integration within existing health care systems of preventive initiatives to maintain independent living among older people is increasingly emphasized. This article describes the development and refinement of the [G]OLD home visitation programme: an eight-step programme, including a comprehensive geriatric assessment, for the early detection of health and well-being problems among older people (C75 years) by general practices. A single group post-test study using a mixed model design is performed to evaluate (a) the feasibility of the home visitation programme in general practice, (b) the practical usefulness of the geriatric assessment instrument, and (c) programme implementation with respect to reinventions introduced by general practitioners (GPs) and practice nurses (PNs). Within 3 months time, 22 PNs of 18 participating general practices visited 240 community-dwelling older people (mean age = 82.0 years; SD 4.2) who had not been in contact with their general practice for more than 6 months. Mean time investment of the programme per older person was 118.1 min (SD 27.0) for GPs and PNs combined. Evaluation meetings revealed that GPs and PNs considered the home visitation programme to be feasible in daily practice. They judged the geriatric assessment to be useful, although minor adjustments are needed (e.g., layout, substitution of tests). PNs often failed to register follow-up actions for detected problems in a care and treatment plan. Future training for PNs should address this issue. No reinventions were introduced that threatened fidelity of implementation. The findings are used to improve the home visitation programme before its evaluation in a large-scale controlled trial.

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Section: Discussionmentioning

confidence: 99%

Development of a home visitation programme for the early detection of health problems in potentially frail community-dwelling older people by general practices

Stijnen

Jansen²,

Vrijhoef

et al. 2012

Eur J Ageing

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“…Additional study details have been published previously. 15,17 The study was approved by the Institutional Review Boards of the Johns Hopkins Bloomberg School of Public Health, Kaiser Permanente Mid-Atlantic States, and MedStar Physician Partners.…”

Section: Methodsmentioning

confidence: 99%

“…20 At the rate of two patients per week, each nurse built a case load of 50-60 patients, each of whom received the eight Guided Care services throughout the study. 15 The nurses received feedback on defined elements of their performance at monthly meetings with the research team. Participating physicians received an orientation to the nurses' role and to the nature of the study, but no compensation for participating or incentives for attaining specific outcomes for their patients.…”

Section: Interventionmentioning

confidence: 99%

“…15,16 The present paper reports the final results of a 32-month study designed to test the hypothesis that Guided Care teams, compared to usual care teams, produce better functional health (primary outcome) and quality of care for their patients with less use of expensive health services (secondary outcomes). Patients were randomized by cluster (i.e., by team of physicians), to acknowledge that Guided Care is a team-level intervention and to minimize contamination across groups.…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2013

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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.

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“…Visits to the NP or PA are earmarked to address a specific chronic condition or conditions and use structured visit notes appropriate to the condition being addressed 31 Nurses, social workers, or psychologists (internal or external to a practice) receive additional specialized training in working with vulnerable elders. 15,18,32 These professionals then provide support to a group of primary care clinicians in assessing patients' and caregivers' needs, in coordinating care, and in counseling patients or family members about chronic conditions An NP/social worker team coupled to a geriatrics interdisciplinary team can provide a high level of external support to the primary care clinician in managing care for low-income vulnerable elders 14 Augmented primary care…”

Section: Delivery Modelsmentioning

confidence: 99%

Key Elements of High-Quality Primary Care for Vulnerable Elders

Ganz

Fung²,

Sinsky

et al. 2008

J GEN INTERN MED

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With the impending surge in the number of older adults, primary care clinicians will increasingly need to manage the care of vulnerable elders. Caring for vulnerable elders is complex because of their wide range of health goals and the interdependence of medical care and community supports needed to achieve those goals. In this article, we identify ways a primary care practice can reorganize to improve the care of vulnerable elders. We begin by identifying important outcomes for vulnerable elders and three key processes of care (communication, developing a personal care plan for each patient, and care coordination) needed to achieve these outcomes. We then describe two delivery models of primary care for vulnerable elders -co-management, and augmented primary care. Finally, we discuss how the physical plant, people, workflow management, and community linkages in a primary care practice can be restructured to better serve these patients.KEY WORDS: primary care; practice redesign; quality of care; quality improvement; older adults.

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Guided Care for Multimorbid Older Adults

Cited by 179 publications

References 45 publications

Development of a home visitation programme for the early detection of health problems in potentially frail community-dwelling older people by general practices

Development of a home visitation programme for the early detection of health problems in potentially frail community-dwelling older people by general practices

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

Key Elements of High-Quality Primary Care for Vulnerable Elders

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