Linking Clinical Practice and Community Resources: The Guided Care Model

1. Linking Clinical Practice and Community Resources:The Guided Care Model Chad Boult, MD, MPH, MBA Professor of Public Health, Medicine and Nursing Johns Hopkins University AHRQ 2009 Annual Conference September 14, 2009

2. Ms. Marian Chen 79 year old widow Retired teacher, lives alone Income: SS, pension and Medicare Daughter, lives 10 miles away with three teenagers Five chronic conditions Three physicians Eight medications

3. 8 Physicians, 6 Social Workers, 5 Physical Therapists, 4 Occupational Therapists, 37 Nurses 22 scripts 6 community referrals 8 meds 19 outpatient visits 2 home care agencies Mrs. Chen 3 hospital admissions 5months homecare 6 weeks sub- acute care 2 nursing homes In 2009, Mrs. Chen has had…

4. Mrs. Chen • Confused by care, meds • Poor quality of life • High out-of-pocket costs • Daughter • Stressed out • Reduced work to half-time • Considering nursing homes Medicare paid $42,400 to providers for her care (not including medications)

5. Chronic care is: Fragmented Discontinuous Difficult to access Inefficient Unsafe Expensive

6. The ¼ of Beneficiaries Who Have 4+ Chronic Conditions Account for 80% of Medicare Spending Source: Medicare 5% Sample, 2001

7. Goals Create a model that improves quality of care and reduces costs Make the model diffusable throughout the United States

8. The Guided Care Model Specially trained RNs based in primary physicians’ offices GCNs collaborate with physicians in caring for 50-60 high-risk older patients with chronic conditions and complex health care needs

9. Nurse/physician team Assesses needs and preferences Creates an evidence-based “care guide” and a patient-friendly “action plan” Monitors the patient proactively Supports chronic disease self-management Smoothes transitions between caresites Communicates with providers in EDs, hospitals, specialty clinics, rehab facilities, home care agencies, hospice programs, and social service agencies in the community Educates and supports caregivers Facilitates access to community services

10. Linking with Community Resources • Data base of local community resources • Facilitate access to appropriate services • Empowerment • Paternalism • Meals on Wheels, senior centers, AAA, transportation programs, adult day care, CDSMP, social workers, pharmacists • GCN support groups  community support groups

11. Health System Health Care Organization ClinicalInformationSystems Electronic Health Record, Care Guide, Transitional Care, Coordination Community Resources and Policies Accessing Self-Management Support Chronic Disease Self-Management DeliverySystem Design Guided Care Nurse Decision Support Lexi-comp, Evidence-based guidelines Prepared, Proactive Practice Team Monitoring Coaching Informed, Activated Patient Chronic Disease Self-Management, Caregiver Support, Action Plan Productive Interactions Improved Outcomes

12. Who is Eligible? All Patients Age 65+ 25% High-Risk 75% Low-Risk Review previous year’s claims data with HCC software

13. Randomized Trial High-risk older patients (n=904) of 49 community-based primary care physicians practicing in 14 teams Physician/patient teams randomly assigned to receive Guided Care or “usual” care Outcomes measured at 8, 20 and 32 months

14. Baseline Characteristics

15. Effects on Physician Satisfaction

16. Very Satisfied Satisfied Somewhat Satisfied Somewhat Dissatisfied Dissatisfied Very Dissatisfied Satisfaction Items 1= Familiarity with patients 2= Stability of patient relationships 3= Comm. w/ patients; Availability of clinical info; continuity of care for patients 4= Efficiency of office visits; access to evidence based guidelines 5= Monitoring patients; communicating w/ caregivers; efficiency of primary care team 6= Coordinating care; referring to community resources; educating caregivers 7= Motivating patients for self management

17. Effects on Quality of Care * Adjusted for baseline socio-demographics, health, function, PACIC scores, site

18. Effects on Caregiver Strain

19. Annual Costs of Guided Care

20. Effects on Costs of Care(per caseload, 55 patients)

21. Early Results • Guided Care improves the quality of chronic care. • Guided Care reduces net expenditures for health care. • Guided Care is easy to implement and popular with physicians, nurses, patients and caregivers.

22. Future Directions National pilot test involving Guided Care medical homes Technical assistance • Book • Online course and certificate for nurses • Online course for physicians • Guidance in selecting HIT • Learning collaboratives and communities • Consultation

23. Grant Support Agency for Healthcare Research and Quality National Institute on Aging John A. Hartford Foundation Jacob and Valeria Langeloth Foundation

24. Publications Boyd C et al. Gerontologist Nov 2007 Sylvia M et al. Dis Manag Feb 2008 Boyd C et al. J Gen Intern Med Feb 2008 Boult C et al. J Gerontology Mar 2008 Wolff et al. J Gerontology June 2009 Leff B et al. Am J Managed Care August 2009 “Guided Care: a New Nurse-Physician Partnership for Chronic Care.” Springer Publishing Co. 2009 (www.springerpub.com/guidedcare) http://www.guidedcare.org