Guided Care was developed to help primary care practices address the growing challenges of a rapidly aging America. By 2025, more than 25% of the U.S. population will be living with multiple chronic conditions, and the cost for managing their care is expected to reach $1.07 trillion.
In Guided Care, a specially-educated registered nurse works in partnership with primary care physicians and connected caregivers to support a practice’s sickest patients by:
- Assessing the patient and their primary caregiver at home;
- Creating an evidence-based care plan for providers and an action plan for patients and caregivers;
- Promoting patient self-management;
- Monitoring patients’ conditions monthly;
- Coordinating the efforts of all care providers (hospitals, specialists, rehab facilities, home care, hospice, and social service agencies);
- Smoothing transitions between sites of care, (e.g., transitions into and out of hospitals);
- Educating and supporting family caregivers;
- Facilitating access to community resources.
Nurses use a web-based electronic health record to track appointments, drug interaction alerts, evidence-based guidelines, and reminders.