Realizing the Benefits of Guided Care Nursing

Realizing the Benefits of Guided Care Nursing

Event Date: 
Thursday, June 3, 2010

This June 2010 Change Exchange spotlighted an innovation on guided care nursing. AHRQ Innovations Exchange readers were invited to listen to the innovators discuss their innovation, read the Innovation profile, and send questions via the comments feature. The complete transcript and questions and answers are below.


Chad Boult, MD, MPH, MBA, Johns Hopkins Bloomberg School of Public Health

Tracy Novak, MHS, Johns Hopkins Bloomberg School of Public Health 


Questions and Answers

Guided Care for Other Populations

Q: Can Guided Care be used to treat younger populations with chronic conditions? Do you have plans to use the model to treat these populations?

Maurice (Research or Consulting Organization; Researcher)

A: Chad Boult and Tracy Novak:

Although we studied the effects of Guided Care on older people, it is probably also appropriate for younger people with several chronic conditions. We have no studies planned for younger populations, but demonstrations and pilots of medical homes, which are being conducted by others across the country, offer opportunities to study Guided Care in younger populations. Visit Visit for more information about these demonstrations and pilots. Visit the AHRQ Health Care Innovations Exchange for information about AHRQ funding opportunities at

Guided Care Nurses and Nurse Practitioners

Q: How much does the Guided Care model in actual practice differ from primary care delivery with intensive nurse practitioner involvement?

Laura (Research or consulting organization; Researcher)

A: Chad and Tracy:

Guided Care nurses have a more limited scope of practice than advance practice nurses. Guided Care nurses do not make diagnoses or prescribe treatments, whereas nurse practitioners do.

Reimbursement for Guided Care

Q: Is reimbursement for Guided Care nursing services limited to the national Medicare Medical Home Demonstration?

Kenneth (Government agency; Researcher)

Q: The trend is for all of us in primary care to establish medical homes to better coordinate care for the chronically ill. Having a trained RN to work in guiding this care could help bring together many loose ends that lead to unnecessary healthcare expenditures. Policymakers in Congress need to understand this to enable funding to support this change, as most practices–particularly Federally Qualified Health Centers like ours–will not be able to assume the expense of these caregivers without some additional funding.

Mitchell (Physician office; Physician)

Q:Is there private insurance interest in reimbursement for this kind of care for either elderly or non-elderly populations?

Shannon (Research or consulting organization; Researcher)

A: Chad and Tracy:

Fee-for-service Medicare does not cover the costs of Guided Care nurses. There are dozens of demonstrations and pilots of the medical home occurring around the country, including the Medicare Medical Home Demonstration, that provide various amounts of payment for the services provided by Guided Care nurses. Visit  for more information about these pilots and demonstrations.

The Federal Government will probably require additional testing of Guided Care before it will consider paying for it as a benefit of the Medicare and Medicaid programs.

At least two managed care organizations are now paying for Guided Care, and several other insurers have also expressed interest.

Guided Care Patients

Q: Can you describe the kinds of patients and caregivers who have been involved with Guided Care Nursing? What do they like most about the program? Like least?

Katharine (Research or consulting organization; Researcher)

Q: Aside from clinical factors such as chronic disease, what other characteristics make some patients better candidates for Guided Care than others?

Anne (Government agency; Researcher)

A: Chad and Tracy:

The ideal patient for Guided Care is an older person with several chronic conditions who is interested in working with a Guided Care nurse to maximize his or her health. Patients with chronic conditions that respond favorably to high-quality ambulatory care—for example, heart failure, diabetes, depression, hypertension, coronary disease, COPD, falls, and incontinence—are especially good candidates.

Typically, Guided Care patients are 75-80 years old, have four to five chronic conditions, have some degree of functional disability, take several prescription medications, and are at high risk for using health services heavily in the coming year. Their family caregivers are usually either spouses or working adult children. More detailed descriptions are provided in the following publications:

  • Boult C, et al. Early Effects of Guided Care on the Quality of Health Care for Multimorbid Older Persons: A Cluster-Randomized Controlled Trial. J Gerontol A Biol Sci Med Sci 2008;63A(3):321-327.
  • Wolff JM, et al. Caregiving and Chronic Care: The Guided Care Program for Families and Friends. J Gerontol A Biol Sci Med Sci 2009;64A(7):785-791.

Feedback from patients and families who receive Guided Care has been very positive. Anecdotal comments include:

  • “It is like having a nurse in the family.”
  • “Having a Guided Care nurse – someone to relieve the anxiety, reconcile the problems, coordinate my care – has been a priceless asset. She is more than a nurse, she is my friend, and I believe she is the missing piece of the health care system.”
  • “My Guided Care nurse has been absolutely indispensable to me. She has made herself readily available whenever I call, and she answers my questions completely. My doctor is often difficult to reach, but my Guided Care nurse will get in touch with my doctor and quickly return to me with the answer. The fact that I always have someone I can totally rely on at all times gives me great confidence and is deeply appreciated.”
  • “As my mother-in-law's primary caregiver, our Guided Care nurse has been a critical asset in getting timely answers to questions and dealing with emergencies, especially when they surface while I am at work.”
  • “My husband's Guided Care nurse has helped me in my role as caregiver. She is a liaison between patient and doctor when I've needed medications, contacts, or even hospitalization. She has given me a lot of moral support. Knowing that I am going to hear from her is a source of strength for me.”

Very few patients have expressed dissatisfaction with Guided Care. Some have noted, however, that their health status has improved to the point that they don't feel they need to talk with the nurse every month.

Using Feedback to Improve Guided Care

Q: You recommend obtaining periodic feedback from physicians, nurses, and patients. How have you done this? Could you describe changes you have made in response to this feedback?

Kristine ( Research or consulting organization; Researcher)

A: Chad and Tracy:

We asked physicians, nurses, and patients for suggestions to improve Guided Care. Based on the feedback we received, we now emphasize:

  • The importance of orienting the physicians and their office staff regarding the goals and processes of Guided Care.
  • The importance of thoroughly integrating the Guided Care nurse into the many processes of the practice.
  • The need to provide physicians with incentives for working in partnership with the Guided Care nurse.

How to Introduce Guided Care into Primary Care Practices

Q: Can you please elaborate on the startup process? Do you provide specific guidance on how to introduce guided care nurses into an established primary care practice?

Susan (Research or consulting organization; Researcher)

A: Chad and Tracy:

Integrating the Guided Care nurse thoroughly into the primary care practice involves an important sequence of activities. These are described in detail in an implementation manual Guided Care: a New Nurse-Physician Partnership in Chronic Care.

Nursing Satisfaction

Q: Have you evaluated nurse satisfaction in this role? What is the staff turnover rate? How was the 50 -60 patient case load determined? Does the course offer a national certification?

Jane (Hospital; Nurse)

Q: Can you please comment on the experience of nurses involved in this innovation? What do they like most about doing this kind of nursing? What are the biggest challenges?

Chris (Research or consulting organization; Business Administrator)

A: Chad and Tracy:

Guided Care nurses report high levels of satisfaction with most activities of the Guided Care nursing role, especially the flexibility of their work hours and the relationships they develop with their patients. They report that the most rewarding aspects of their role relate to interactions with patients, their families, and the primary care providers. One of their challenges is helping the physicians and office staff members to understand that a Guided Care nurse cannot provide Guided Care to patients who do not quality to receive it.

For more information, read the article by Giddens JF et al. Expanding the Gerontological Nursing Role in Guided Care. Geriatric Nursing 2009;30(5)358-364. During the study we conducted, all seven nurses who were integrated into primary care practices remained in those positions throughout the period for which they had been hired.

The case load of 50-60 patients per nurse was determined by surveying other similar intensive care management programs, such as those that served renal dialysis patients and HIV/AIDS patients

Community Resources

Q: What community resources has your innovation more heavily tapped? How have you been able to facilitate their access?


A: Chad and Tracy:

The community resources used most frequently are transportation services, Meals-on-Wheels, adult day care centers, senior centers, local Area Agencies on Aging, support groups, and disease-specific services provided by groups such as the Alzheimer's Association and the American Diabetes Association. The online Guided Care Nursing course includes a module on identifying community resources and suggestions about how a nurse can develop and maintain a relationship with each organization. Each nurse maintains a data base that includes all the relevant information for all of the community resources available in the local area.

Electronic Health Records (EHRs)

Q: The innovation mentions the importance of a Web-based EHR specially designed for the program. It also notes that existing EHRs can be modified to provide needed functionality. Can you briefly describe the central characteristics of the Web-based EHR that are needed to support this program?

Martha (Research or consulting organization; Researcher)

A: Chad and Tracy:

The Guided Care nurse uses a secure web-based EHR that:

  • Incorporates into each patient's comprehensive care plan the current evidence-based guidelines for managing the most prevalent chronic conditions.
  • Checks the patient's medications for possible adverse interactions.
  • Documents contacts with patients, families and health care providers.
  • Reminds the nurse of events or actions scheduled for each day.

We are working with several vendors to incorporate these functions into existing and new commercial products, which they will make available to practices.

Advantages of Widespread Adoption of Guided Care Nursing

Q: It looks like eight primary care practices and two managed care partners have so far used Guided Care nursing. Could you describe some economies of scale that could be realized if it were more widely adopted?

William (Research or consulting organization; Researcher)

A: Chad and Tracy:

Insurers or other organizations could identify patients who are eligible to receive Guided Care. Networks of practices could hire and manage a group of Guided Care nurses who could work in the network's practices and cover each other during vacations and other absences.

Impact on Health Care Quality

Q: Does this program actually increase health care quality or improve outcomes?

Deb (Research or consulting organization; Researcher)

Q: You mentioned that patient-reported quality of care was higher using Guided Care nursing. Have you measured quality of care in other ways?

Josh (Researcher)

Q: Are there chronic conditions that Guided Care Nursing has been particularly successful in addressing?

Christine (Research or consulting organization; Consultant)

A: Chad and Tracy:

Two articles have reported that Guided Care patients are more than twice as likely as other similar patients to rate the quality of their health care in the highest category:

  • Boult C, et al. Early Effects of Guided Care on the Quality of Health Care for Multimorbid Older Persons: A Cluster-Randomized Controlled Trial. J Gerontol A Biol Sci Med Sci 2008; 63A (3):321-327.*
  • Boyd CM, et al. The Effects of Guided Care on the Perceived Quality of Health Care for Multi-morbid Older Persons: 18-Month Outcomes from a Cluster-Randomized Controlled Trial. J Gen Intern Med 2010; 25(3):235-242.

*The number of patients with any specific condition in our cluster-randomized controlled trial of Guided Care was too small to conduct meaningful analysis of disease-specific quality indicators.

Therefore, we have not analyzed subgroups of patients with specific conditions to see if Guided Care is more effective in addressing some conditions than others. We hypothesize that it is probably most effective at improving outcomes for patients who have “ambulatory care sensitive conditions” such as heart failure, diabetes, hypertension, etc.

Other articles report that Guide Care reduces the net costs of health care. See, for example:

  • Leff B, et al. Guided Care and the Cost of Complex Healthcare: A Preliminary Report. Am J Manag Care 2009;15 (8):555-559.

It is also associated with reductions in family caregivers' perception of the strain of caregiving. See:

  • Wolff JM, et al. Caregiving and Chronic Care: The Guided Care Program for Families and Friends. J Gerontol A Biol Sci Med Sci 2009; 64A (7):785-791.
  • Wolff JM, et al. Effects of Guided Care on Family Caregivers. Gerontologist 2009 Aug 26 (Epub ahead of print).




Hello, I'm Chad Boult, Director of the Roger C. Lipitz Center for Integrated Health Care in the Department of Health Policy and Management at Johns Hopkins Bloomberg School of Public Health.


And I'm Tracy Novak, Director of Communications for the Lipitz Center and Project Director of the Johns Hopkins Medicare Medical Home Demonstration Technical Assistance Program.


We want to share with you results of our research on Guided Care – and encourage you to consider how you might use these findings in your own practices. In Guided Care, a registered nurse, who is based in a primary care practice, works with 3-4 physicians to provide comprehensive care for 50-60 chronically ill patients. Guided Care is evidence-based, state-of-the-art chronic care from a professional team that the patient trusts.


We focused on the specific goal of improving the delivery of health care for a challenging population: elderly patients with multiple chronic illnesses – and the results have been very promising. Compared to usual care patients, Guided Care patients were twice as likely to rate the quality of their care highly. Patients’ total health care costs, including the costs of Guided Care, were 11% lower in the first 8 months of the randomized trial.


Physicians were significantly more satisfied with their patient and family communication and with their knowledge of their chronically ill patients' clinical conditions. Family caregivers of Guided Care patients reported less strain, especially among caregivers who provided more than 14 hours of weekly assistance. Citations for the published results of a pilot study and of a multi-site randomized controlled trial are posted on the Innovations website.


There are also links to several forms of technical assistance for practices that want to adopt Guided Care. The Institute for Johns Hopkins Nursing offers a six-week, forty-hour, online course in Guided Care Nursing for RN's. Upon completion of the course, participants are eligible to take an online examination leading to a Certificate in Guided Care Nursing from the American Nurses Credentialing Center.


The Lipitz Center’s Medicare Medical Home Technical Assistance program also offers an asynchronous, online, nine-hour course called “Practice Leaders in Medical Homes” for physicians, practice administrators and other practice leaders. Physicians earn one CME credit from AMA per one-hour module. In addition, we’ve written an implementation manual to help practices to adopt Guided Care.


But here's the problem: it costs $96,000 a year to add a Guided Care nurse to a primary care practice. And there's not a lot of margin in primary care medicine.


The Patient-Centered Primary Care Collaborative might be a great resource to help with this. There are dozens of demonstration projects being started in communities all around the country to test the medical home concept. Not every community has one, but participating in one of these demonstrations might provide a source of funding to help practices offset the costs of Guided Care.


Practices can find out whether there is a medical home demonstration in their area by visiting the website of the Patient-Centered Primary Care Collaborative at


Add your voice to this exchange. Go to Enter “guided care nursing” in the search box at the top of the page. And click the link to review the profile of this study. For two weeks after the release of each podcast we invite you to submit questions, share stories, or offer suggestions using the Comment feature in the profile. We'll then ask the innovators to respond, and will publish that podcast on the Innovations Exchange. We look forward to hearing from you.

This website is certified by Health On the Net Foundation. Click to verify. This site complies with the HONcode standard for trustworthy health information: verify here.