The Guided Care Solution

As Americans live longer, many develop chronic health conditions that require complex care. By the year 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. The fragmented U.S. healthcare system often does not serve the sickest very well. The Institute of Medicine calls the current system “a nightmare to navigate.” Many of the elderly and those who care for them would agree. Click here for more chronic care facts and resources.

A number of solutions have been developed to address this problem, but none is as personal and comprehensive as Guided Care. While disease management and case management programs often focus on one or a few chronic conditions, the Guided Care Nurse manages all of a patient’s health care needs in the home, the doctors’ offices, the hospital, and the community. Guided Care is based on proven innovations and the Chronic Care Model.

In Guided Care, a specially-educated registered Guided Care Nurse, based in a primary care practice, works in partnership with 2-5 primary care physicians and other members of the health care team in providing 8 processes to 50-60 chronically ill patients. The 8 inter-related clinical processes of Guided Care combine scientific evidence with patients' preferences, priorities, and values:

1. Assessing the patient and primary caregiver at home;
2. Creating an evidence-based comprehensive "Care Guide" (care plan) for providers and a patient-friendly "Action Plan" for patients and caregivers;
3. Promoting patient self-management;
4. Monitoring patient's conditions monthly;
5. Coordinating the efforts of all health care providers, including hospitals, emergency departments, specialty clinics, rehab facilities, home care agencies, hospice programs, and social service agencies;
6. Smoothing transitions between sites of care, focusing more intensively on transitions into and out of hospitals;
7. Educating and supporting family caregivers;
8. Facilitating access to community resources.

A secure web-accessible electronic health record assists the Guided Care Nurse with drug interaction alerts, evidence-based guidelines, reminders, and tracking of encounters with health care professionals.

To view a short video on the Guided Care program, click here. For more information, view our list of Frequently Asked Questions.