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APHA Scientific Session and Event Listing

Charles E. Boult, MD, MPH, MBA¹, Bruce Leff, MD², Cynthia Boyd, MD³, Lisa Semanick¹, Rosemarie Brager, PhD, CRNP⁴, and Katherine P. Frey, MPH¹. (1) Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Roger C. Lipitz Center for Integrated Health Care, 624 N. Broadway, Room 653, Baltimore, MD 21205, 410-955-6546, cboult@jhsph.edu, (2) Johns Hopkins University Schools of Medicine and Public Health, 5505 Hopkins Bayview Circle, Baltimore, MD 21224, (3) The Johns Hopkins Bayview Care Center, 5505 Hopkins Bayview Circle, Baltimore, MD 21224, (4) Johns Hopkins University School of Nursing, 525 N. Wolfe St, Room 421, Baltimore, MD 21205

Health care for multi-morbid older Americans is often fragmented and lacking in quality and efficiency. To address the mismatch between the acute-care orientation of the U.S. health care system and the complex clinical needs of the multi-morbid older population, investigators at the Johns Hopkins University Schools of Public Health, Medicine, and Nursing have created ”Guided Care.” This model infuses contemporary primary care with state-of-the-art information technology and seven innovations in chronic care: disease management, case management, self-management, coaching for health enhancement, transitional care, caregiver education and support, and geriatric evaluation and management. Based in the primary care office and equipped with secure, web-accessible, information technology, each “Guided Care Nurse” collaborates with 2-4 physicians to provide high-quality chronic care to 50-60 multi-morbid older patients. The nurse assesses patient's health status and works with the physician, the patient, and the family to create an evidence-based “Care Guide” that incorporates the patient's priorities and intentions. Thereafter, the nurse monitors the patient's chronic conditions, facilitates self-management, coaches the patient toward a healthy life style, smoothes transitions between health care providers, teaches and supports family caregivers, and facilitates access to community services. In a pilot study, Guided Care was superior to “usual care” in both the quality and the costs of chronic care. A five-year randomized controlled trial in eight community primary care practices in Baltimore and Washington DC is now evaluating the effects of Guided Care on the quality and outcomes of care for chronically ill older persons, family caregivers, and primary care practices.

Learning Objectives: At the conclusion of this session, the participant will be able to

• Describe the failings of chronic care in America;
• Descirbe the innovations in chronic care provided by Guided Care.

Keywords: Chronic Diseases, Primary Care

Presenting author's disclosure statement:

Not Answered