Boult CE (Johns Hopkins Bloomberg School of Public Health)
To measure the effects of “Guided Care” on chronically ill patients’ quality of care and use of inpatient services.
Guided Care (GC) is primary care in which a specially trained registered nurse works on-site with 2-5 primary care physicians in providing eight services for 50-60 chronically ill patients: 1) assessing the patient and caregiver at home, 2) creating an evidence-based care plan, 3) promoting patient self-management, 4) monitoring the patient monthly, 5) coaching the patient to practice healthy behaviors, 6) coordinating the patient’s transitions between sites and providers of care, 7) educating and supporting family caregivers, and 8) facilitating access to community resources. We are conducting a cluster-randomized trial of GC (versus Usual Care, UC) in the community-based practices of 49 primary care physicians in the mid-Atlantic United States. Participants are patients age 65 years or older who have a twice-average probability of using health services heavily during the following year, according to the claims-based Hierarchical Condition Category (HCC) predictive model. Participants’ health care is insured by Tricare, Kaiser-Permanente, or fee-for-service Medicare. Here we compare the GC and UC groups’ quality of care and use of inpatient health services (for Tricare and Kaiser-Permanente members, n = 522) through the first six months of the study. Data on Medicare beneficiaries will become available later in 2007. Quality of care was measured at baseline and six months later by blinded telephone administration of the Patient Assessment of Chronic Illness Care (PACIC). Use of hospital and skilled nursing facilities (SNF) was quantified from “admission authorization” data provided by the patients’ health insurers.
Compared to controls, more than twice as many GC patients rated their health care in the highest quality category (aOR = 2.6, 95% CI = 1.3 – 4.8). The two groups’ use of hospital days was similar, but the GC group used 66.3% fewer SNF days.
For chronically ill patients, GC produced better clinical and utilization outcomes than usual care.
If the final results of this study remain positive, Guided Care may become a national model for providing cost-effective health care to patients with chronic conditions.