Guided care: Improving chronic care for high-risk seniors (Winner of the 2008 Archstone Foundation Award)

The nation's health care delivery system performs well for people in good health who experience acute illnesses, but it often fails older Americans who have several chronic conditions and complex care needs. The scientific principles of seven successful innovations were translated into one high-tech, high-touch system of chronic care called Guided Care, which is designed to improve the quality, outcomes and efficiency of health care for high-risk older persons. In Guided Care, a registered nurse, based in a primary care practice, partners with 2-5 physicians to provide comprehensive chronic care for 50-60 patients. The eight inter-related clinical processes of Guided Care combine scientific evidence with frail older persons' goals, values and priorities. Most primary care physicians who have at least 300 older patients in their practice have a minimum of 50-60 multi-morbid older patients who could benefit from the services of a Guided Care nurse.

In 2006, a 30-month, cluster-randomized controlled trial of Guided Care was launched in the mid-Atlantic region of the US for 904 older adults with complex chronic health conditions and 308 of their family caregivers. Six-month data show that Guided Care improves the quality of care, reduces health care costs, and produces high job satisfaction among physicians and nurses. If those savings continue throughout the RCT, this would provide a rational for Medicare and other insurers to pay for Guided Care services. A dissemination strategy is being implemented to make Guided Care a national model for providing cost-effective health care to older patients with complex needs.