It takes a team: Affordable care act policy makers mine the potential of the guided care model

Guided Care aims to improve quality of care and life for patients with multiple chronic conditions, to reduce caregiver burden, to improve physicians' professional satisfaction, and to reduce healthcare costs. Mrs. Shirley Jefferson is a 79-year-old widowed, retired school teacher who lives in an apartment and receives Social Security, a modest pension, and traditional fee-for-service Medicare. Her primary source of personal assistance and emotional support is her daughter, Lisa Walker, who works a fulltime job and lives ten miles away with her husband and three teenagers. Mrs. Jefferson sees Dr. Greg Martin, a primary care physician, for routine office visits every three months, and two outpatient specialty physicians for five chronic conditions. She is taking eight prescription medications. During the past year, she filled twenty-two prescriptions, had nineteen outpatient visits, three hospital admissions, spent six weeks in sub-acute care, had two nursing home stays, and received five months of home health care from two home health agencies. Her care was administered by eight physicians, six social workers, five physical therapists, four occupational therapists, and thirty-seven nurses. Medicare paid $45,000 to providers for her care; Shirley Jefferson's out-of-pocket costs were $4,700. Dr. Martin is concerned that Mrs. Jefferson is not properly taking the prescribed medications, and he doesn't know what medications, diet, or activities her other doctors have recommended. He says he wishes he had more time to discuss this, but office visits barely last long enough to complete a physical exam and renew necessary prescriptions. Mrs. Jefferson is confused by her care, her multiple medications, and her healthcare bills; she adheres poorly to recommendations because she cannot remember instructions, and she says she is discouraged about what to do. When a problem arises, she doesn't know who to contact, so she calls her daughter. Lisa Walker's caregiving duties cause her significant stress-she has had to reduce her work hours to half time, and she is unable to keep up with her children's demanding schedules. She is considering placing her mother in a nursing home. Shirley Jefferson and her daughter need help. Guided Care: A Team Approach with Quality Outcomes Developed by a multidisciplinary team at Johns Hopkins University in 2002, Guided Care is a comprehensive, team-based model of primary care designed to improve the quality of care and life for people like Shirley Jefferson. It also aims to reduce the burden for caregivers like Lisa Walker, to improve the professional satisfaction of physicians like Dr. Martin, and to reduce total healthcare costs. Guided Care integrates seven successful innovations-disease management, self-management, case management, lifestyle modification, transitional care, caregiver education and support, and geriatric evaluation and management-with primary care to make evidence-based, state-of-the-art chronic care continuously available from professionals whom the patient trusts (Boyd et al., 2007). In Guided Care, a specially trained registered nurse, based in a primary care practice, works in partnership with two to five physicians to provide high-quality care for fifty to sixty chronically ill patients. These patients are members of the practice's panel, and have a risk of heavy healthcare use during the next year in the top 20 percent to 25 percent. The risk is computed from insurance claims using the Hierarchical Condition Category predictive model (Pope et al., 2004). (See sidebar below for the eight interrelated clinical processes of Guided Care.) Results from a recent thirty-two-month, multisite, cluster-randomized controlled trial in eight primary care practices in the Baltimore-Washington, D.C., region (n=904) suggest that Guided Care has the following effects upon care delivery: * Improved quality of patient care. After eighteen months, Guided Care patients were twice as likely as patients in the control group to rate the quality of their care in the highest category (Boyd et al. …