Care For the Whole Person, For Those Who Need it Most

Guided Care is a new solution to the growing challenge of caring for older adults with chronic conditions and complex health needs. A Guided Care Nurse, based in a primary care office, works with patients and their families to improve their quality of life and make more efficient use of health services. The nurse assesses patient needs, monitors conditions, educates and empowers the patient, and works with community agencies to ensure that the patient’s healthcare goals are met.

In a pilot study, patients who received Guided Care rated their quality of care significantly higher than patients who received usual care. In addition, the average insurance costs for Guided Care patients were 25% lower over a six month period. The program is currently being tested at eight primary care sites in the Baltimore-Washington D.C. area in a randomized trial involving over 900 patients, 300 caregivers, and 48 primary care physicians. Click here for a summary of pilot outcomes and preliminary data from the trial.

Guided Care is the winner of the American Public Health Association's 2008 Archstone Foundation Award for Excellence in Program Innovation. The award, established by an endowment from the Archstone Foundation, recognizes one innovative model of care for older Americans each year.

A book titled "Guided Care: A New Nurse-Physician Partnership in Chronic Care" was released by Springer Publishing on Feb 23, 2009, to serve as an implementation manual for practices that want to adopt Guided Care. Click here for more information.

To learn about the technical assistance available to the participants of the Medicare Medical Home Demonstration, please visit www.medhomeinfo.org.