The purpose of the study is to evaluate the effect of a Guided Care nurse on the quality of
the health and well-being of the frail elderly. A specially trained registered nurse will
work closely with 1-3 primary care physicians to provide the most complex older patients
(and their unpaid caregivers) with health care that is comprehensive, coordinated,
patient-centered, and proactive. The study will evaluate the effects of Guided Care on:
- older persons' physical and mental health, health services utilization, quality of
care, self-efficacy, and satisfaction with care;
- older persons' unpaid caregivers' burden; and
- primary care physicians' satisfaction with their care of chronically ill patients.
Health care for older Americans with chronic conditions is often fragmented and
provider-centric. In response, a team of investigators at Johns Hopkins University has
translated the scientific principles of seven successful innovations into one
patient-centered system of care. Supported by evidence-based guidelines and state-of-the-art
information technology, "Guided Care" is undergoing a 12-month pilot test in older primary
care patients with complex needs. A specially trained Guided Care nurse (GCN), based in a
primary care practice, collaborates with two primary care physicians to provide seven
services for 40-60 high-risk patients: comprehensive assessment and care planning; "best
practices" for chronic conditions; self-management; healthy lifestyles; coordinating care;
educating and supporting unpaid caregivers; and accessing community resources.
The proposed multi-site study will measure the effects of Guided Care on the quality and
outcomes of care for high-risk older persons, their unpaid caregivers, and their primary
care physicians. The panels of 53 physicians in 7 practices will be screened to identify
1350 high-risk older patients. After about 850 have given informed consent and baseline
interviews, clusters of 2-5 physicians at each practice site will be randomized to provide
either Guided Care or usual care to their consenting patients. Each physician cluster in the
Guided Care group will incorporate a GCN into its practice; the physician clusters in the
control group will not.
Interviews and queries of administrative databases will provide evaluative data at baseline
and at 12-, 24-, and 32-month follow-up intervals. The primary outcome variables are the
participants' physical health and mental health (SF-36 Summary Scales) and health services
utilization. Secondary outcome variables include: the quality of care; unpaid caregivers'
burden; self-rated health; patient satisfaction; and primary care physicians' satisfaction.
Intention-to-treat analyses will have 85% power (range of 70-97%) to detect clinically
meaningful differences between the two groups.
The study is designed to facilitate the prompt dissemination of Guided Care, if the results
of the trial are favorable. A stakeholders' advisory board, representing consumers,
providers, delivery systems, insurers, regulators and policy-makers, will inform the
operation and evaluation of the study - and it will facilitate the subsequent dissemination
of its tools and technology throughout American health care.
- Over 65
- Insured by KPMAG, USFHP/TRICARE, or Medicare FFS
- High likelihood of use of services in the coming year based on predictive modeling
using current year's health care expenses
- Moving out of area
- Currently assigned to case manager/in case management program
- Cognitive impairment and no legal representative
Charles Boult, MD, MPH, MBA
Johns Hopkins Bloomberg School of Public Health