Onsite Nurses Manage Care Across Settings to Increase Satisfaction and Reduce Cost for Chronically Ill Seniors

Service Delivery Innovation Profile

Onsite Nurses Manage Care Across Settings to Increase Satisfaction and Reduce Cost for Chronically Ill Seniors

Snapshot

Summary

Specially trained nurses work with primary care physicians in their offices to improve care for seniors with multiple chronic illnesses by coordinating care, facilitating transitions in care, and acting as the patient's advocate across health care and social settings. Nurses use an electronic health record and a variety of established methods, including disease management, case management, transitional care, self-management, lifestyle modification, caregiver education and support, and geriatric evaluation and management. The program, known as “Guided Care,” has significantly increased patient and family perceptions of quality, improves physician satisfaction with chronic care, improves nurse job satisfaction, and may reduce costs and utilization.

Evidence Rating

Strong: The evidence consists of results from an eight-site, cluster-randomized controlled trial that measured patient and caregiver perceptions of quality; costs and utilization; caregiver strain; and physician and nurse satisfaction.

Developing Organizations

Johns Hopkins Bloomberg School of Public Health

Baltimore, MD

Use By Other Organizations

Assuming that research trial results continue to be positive, program developers plan to disseminate the model throughout the American health care system. Two of the managed care partners in the trial have continued to provide Guided Care following the completion of the trial, and other managed care organizations have expressed an interest in the program. Information provided in April 2011 indicates that three organizations have executed a Guided Care license agreement with Johns Hopkins University, and seven license agreements are in negotiation.

Date First Implemented

2003

Problem Addressed

Many older adults have multiple, costly chronic conditions, and these individuals often receive care from a myriad of health care providers, resulting in fragmented, uncoordinated care that hampers effective management of patients' health care needs and quality of life.

  • Many older adults with multiple, costly chronic conditions: Almost three-fourths of individuals aged 65 years and older have at least one chronic illness, while about one-half have at least two chronic illnesses. More than 92 percent of Medicare spending in 2002 was incurred by beneficiaries with three or more chronic conditions. As baby boomers age, the number of people with one or more chronic conditions will increase.
  • Fragmented care that reduces effectiveness: More than one-half of patients with serious chronic conditions receive treatment from three or more different physicians. One study found that care fragmentation across physicians and care sites contributed to an increased likelihood of hospitalization for seniors with chronic illnesses, even when alternative sites are available.

Description of the Innovative Activity

The “Guided Care” program places a specially trained registered nurse, known as a Guided Care Nurse, onsite at a primary care practice; each guided care nurse coordinates care for 50 to 60 elderly patients who have multiple complex chronic conditions. Supported by an electronic health record (EHR) and using a variety of established methods, including disease management, case management, transitional care, self-management, lifestyle modification, caregiver education and support, and geriatric evaluation and management, each nurse works with two to five primary care physicians (PCPs), specialists, caregivers, and community resources to coordinate and improve patient care across health care providers and settings. Key elements of the program include the following:

  • Identifying at-risk patients who can benefit from the program: Eligible patients are aged 65 years and older; have multiple, complex conditions; and are expected, in the absence of any intervention, to have high health expenditures in the near future. These patients are identified through a review of 12 months of health insurance claims and use of a predictive model (Medicare's hierarchical condition category predictive model) to identify the 20 to 25 percent of older patients who have the highest predicted need for complex health care in the near future.
  • Specially trained nurses placed in primary care practices: Specially trained registered nurses serve as Guided Care Nurses, working onsite at primary care practices. Each Guided Care Nurse coordinates care for a caseload of 50 to 60 older patients who have several chronic conditions.
  • Ongoing care coordination: Guided Care Nurses work with PCPs, specialists, caregivers, and community organizations to coordinate and improve patient care across providers and settings. Eight clinical processes are provided:
    • Comprehensive assessment: The Guided Care Nurse performs an initial assessment of the patient's medical, functional, cognitive, affective, psychosocial, nutritional, and environmental status during a home visit, and asks the patient about his/her priorities for optimizing health and quality of life.
    • Evidence-based care planning: The Guided Care Nurse and the PCP work collaboratively with the patient and caregiver to develop an individualized Care Guide and a patient-friendly Action Plan.
    • Promoting patient self-management: Based on each patient's Action Plan, the Guided Care Nurse promotes and reinforces self-management skills, promotes the patient's confidence in managing his/her chronic conditions, and encourages each patient to take personal responsibility for his/her health. The Guided Care Nurse also refers the patient to local chronic disease self-management courses, where available.
    • Monthly monitoring of the patient's conditions: The Guided Care Nurse monitors the patient at least monthly by telephone to detect and address emerging problems promptly; the nurse discusses problems with the PCP and takes appropriate action.
    • Coordinating the efforts of all health care providers: The Guided Care Nurse coordinates the efforts of all health care professionals who treat Guided Care patients across health settings.
    • Smoothing transitions between sites of care: The Guided Care Nurse smooths the patient's path between all sites and providers of care by sharing the patient's Care Guide with providers, monitoring patients in the hospital, preparing patients for discharge, conducting a home visit on the patient's return home, and keeping the PCP informed of the patient's status.
    • Caregiver education and support: For the family or other unpaid caregivers, the Guided Care Nurse offers individual assistance, including an in-person assessment and ad-hoc telephone consultation.
    • Facilitating access to community resources: The Guided Care Nurse facilitates patients' and caregivers' access to community-based services for transportation, meals, and adult day care centers, etc., and assists them in accessing these resources efficiently.
  • Use of EHR: Guided Care Nurses access a secure Web-based EHR that was specially designed for the program. The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions. Guided Care Nurses use the EHR to document care; review medications and test data; generate the Care Guide and Action Plan; and document contacts with patients, families, and health care providers.

Context of the Innovation

The Guided Care model was developed by a multidisciplinary team of clinicians and researchers at Johns Hopkins University beginning in 2001. This team identified the need to better support the care and care transitions of chronically ill older patients and wanted to integrate that care within the primary care setting. The team is supported by a Stakeholder Advisory Committee, composed of national leaders from important stakeholders in chronic care, including health care professionals, health insurers, health care delivery systems, nursing educators, consumers, community services, policy makers, and regulators. The team set out to design and evaluate a practical model of care that could succeed in most U.S. primary care practices.

Results

A multiyear, cluster-randomized controlled trial (RCT) conducted at eight sites (including more than 900 patients, 300 family caregivers, and 49 PCPs) in the Baltimore-Washington, D.C. area revealed that Guided Care improves patient and caregiver perceptions of quality, produces high satisfaction among physicians, and may significantly reduce utilization and cost.

  • Higher quality as perceived by patients and family caregivers: After 18 months, Guided Care patients were twice as likely as usual care patients to rate the quality of their care highly. Caregivers of Guided Care patients reported that the quality of chronic illness care received by their loved one to be significantly higher than usual caregivers.,
  • May lower costs and utilization: After 20 months, Guided Care patients experienced, on average, 30 percent fewer home health care episodes, 21 percent fewer hospital readmissions, 16 percent fewer skilled nursing facility days, and 8 percent fewer skilled nursing facility admissions (only the reduction in home health care episodes was statistically significant). Guided Care produced even larger reductions in a subset of patients who received their primary care from one well-managed health system (Kaiser Permanente).
  • Less work-related impact on family caregivers: After 18 months, family caregivers employed in addition to their caregiving role also reported increased work productivity, low absenteeism, and a decline in presenteeism.,
  • Higher physician and nurse satisfaction: Physicians who practiced Guided Care for 1 year rated their satisfaction with patient/family communication and their knowledge of their chronically ill patients' clinical conditions significantly higher than did their peers in the control group. Guided Care Nurses reported a high regard for most aspects of their jobs, consistently expressing high satisfaction with work hour flexibility and the model of care they provide.

Evidence Rating

Strong: The evidence consists of results from an eight-site, cluster-randomized controlled trial that measured patient and caregiver perceptions of quality; costs and utilization; caregiver strain; and physician and nurse satisfaction.

Planning and Development Process

Key steps in the planning and development process include the following:

  • Nurse training: The Guided Care program team developed a course to teach registered nurses the skills needed to practice Guided Care. The 6-week, 40-hour Web-based curriculum covers chronic disease management, patient preferences, case management, geriatric assessment and care planning, transitional care, information technology, motivational interviewing and patient education, evidence-based guidelines, ethno-geriatrics, community resources, communication with physicians, and insurance benefits.
  • Recruitment of Guided Care Nurse candidates: Job advertisements were placed by the two partner health care organizations, drawing many applications; successful candidates had to have completed the training course described above.
  • Integration into primary care practices: Guided Care Nurses were integrated into the primary care practices over a 3- to 5-month period; the goal was to enable them to become effective members of the practice team and to educate practice staff about the Guided Care Nurse role. Once settled into the primary care clinics, the Guided Care Nurses spent time working with the PCPs and office staff to build a caseload of 50 to 60 patients. No training was required for the PCPs or office staff.
  • Coordination of a chronic disease self-management course : Program leaders worked with Stanford University to offer a chronic disease self-management course for Guided Care patients. ( Many states have implemented and are now offering this chronic disease self-management course to residents through funding from the U.S. Administration on Aging.)
  • Development of caregiver support: Program leaders developed a tool to evaluate caregivers and a set of information for Guided Care Nurses to provide to caregivers of Guided Care patients.
  • Community resources assessment : Each Guided Care Nurse developed a list of community resources for patients and caregivers. In addition, Guided Care Nurses visited their local Area Agencies on Aging to familiarize themselves with resources available within the local community.

Resources Used and Skills Needed

  • Staffing: The ideal Guided Care Nurse candidate is a licensed registered nurse with at least 3 years of home care, case management, community health, and/or equivalent gerontologic nursing experience. As noted, each nurse handles between 50 and 60 patients.
  • Costs: Each Guided Care Nurse costs about $96,000 annually to support, including salary, benefits, office space, and expenses (e.g., computer, cell phone, travel). Additional costs include training and EHR-related expenses. Physician practices with an EHR could build program-specific elements into their existing systems. Tuition for the online Guided Care Nurse Course and Certificate cost $1,900 per learner. Current members of the National Gerontological Nursing Association and the Case Management Society of America are eligible for discounted tuition of $1,500. Group and other professional organization discounts are available. Send an e-mail to guidedcare@son.jhmi.edu for more information about all discounts and for additional course information.

Funding Sources

Funding has been provided by a variety of sources. Johns Hopkins HealthCare and Kaiser Permanente Mid-Atlantic States each continue to employ several Guided Care Nurses.

Tools and Resources

More information on the program is available at http://www.guidedcare.org/adopting-guided-care.asp. Contact the innovator for additional information and other tools for potential adopters including:

  • EHR functions
  • Overview of chronic disease self-management programs
  • Outline of the Guided Care Nurse curriculum
  • Guided Care Nurse job description and recruitment posting

An implementation manual, entitled Guided Care: A New Nurse-Physician Partnership in Chronic Care (Springer Publishing Company, 2009), provides detailed, practical information and advice on how to assess whether a practice should adopt Guided Care, and, if so, how to implement and finance the program.

Transformation: A Family's Guide to Chronic Care, Guided Care, and Hope by Tom Grundner (Fireship Press, 2010) describes Guided Care to chronically ill patients and their families; the book is available in English and Spanish, in hard copy and electronic formats, and an audio version is coming soon.

Information on a “Guided Care Nursing” online course and the American Nurses Credentialing Center's new Certificate in Guided Care Nursing is available at: http://www.hopkinsmedicine.org/institute_nursing/.

Getting Started with This Innovation

  • Identify older patients who are most likely to benefit: Maximizing the program's value requires accurate identification of individuals with multiple comorbidities and complex health care needs. Use of predictive models such as Medicare's hierarchical condition category can accomplish this task.
  • Guided Care Nurse recruitment, training, and practice: Nurses from a wide variety of backgrounds can provide Guided Care, although training about the elements of Guided Care is essential. Daily teamwork between the primary care providers and the Guided Care Nurse is essential.
  • Ensure adequate caseload: The caseload needed to support a Guided Care Nurse within the clinic is about 50 to 60 older patients with multiple chronic conditions. Most PCPs (including general internists and family physicians) who provide care to 300 or more older individuals have at least 50 to 60 patients who could benefit from the services of a Guided Care Nurse.
  • Consider sharing nurses across sites: Although the Guided Care studies are based on one nurse at each site, nurses could potentially be shared across two or more practices.
  • Allow for appropriate startup time: Three to 5 months should be allowed for Guided Care Nurses to become integrated into the primary care practice and build up their caseload of patients and caregivers. Integration into practice works best when the practice team is clear about the role of the Guided Care Nurse, and they recognize the Guided Care Nurse as a team member.
  • Provide office space: The practice must provide office space for the Guided Care Nurse that allows the nurse easy access to the physicians to facilitate communication.
  • Provide Internet connection and laptop: Guided Care Nurses should be provided with a laptop and an Internet connection that allows updated patient information to be entered into the EHR. Practices with EHRs in place can build program-specific functionality into their existing systems.
  • Set up mechanism to notify nurses of hospitalizations: Guided Care Nurses need to be notified when one of their patients is hospitalized; notification can come from the practice or through a partnership with hospitals in the area.

Sustaining This Innovation

  • Work with payers to support reimbursement mechanisms: An ongoing funding stream is critical to the sustainability of this type of program. At present, program leaders are building a business case to support reimbursement of program services by managed care organizations and Medicare. PCPs can use the Guided Care model to transform into patient-centered medical homes or Accountable Care Organizations (ACOs) to improve the care of patients with multiple chronic conditions. The Affordable Care Act of 2010 may present new opportunities for use of the Guided Care model.
  • Obtain periodic feedback from physicians, nurses, and patients: Sustained, successful operation of this program depends on obtaining periodic feedback from physicians, nurses, and patients and adjusting interactions accordingly.

Use By Other Organizations

Assuming that research trial results continue to be positive, program developers plan to disseminate the model throughout the American health care system. Two of the managed care partners in the trial have continued to provide Guided Care following the completion of the trial, and other managed care organizations have expressed an interest in the program. Information provided in April 2011 indicates that three organizations have executed a Guided Care license agreement with Johns Hopkins University, and seven license agreements are in negotiation.

Lessons Learned

The Guided Care model has received widespread recognition. Selected honors are listed below (for a complete listing, see http://www.guidedcare.org/news-awards.asp ):

  • 2008 Archstone Foundation Award for Excellence in Program Innovation, from the American Public Health Association
  • 2009 Medical Economics Award for Innovation in Practice Improvement, cosponsored by the Society of Teachers of Family Medicine, the American Academy of Family Physicians, and Medical Economics magazine
  • Finalist, 2010 Getting Research into Practice Award, from the British Medical Journal Group
  • 2010 Case In Point Platinum Award for Case Management Provider Program (won by the Guided Care Program at Kaiser Permanente) and 2011 Sliver Crown Award (won by Guided Care Program at Johns Hopkins Healthcare), awarded by Dorland Health

Other Info

A Guided Care Nurse course may be offered to a small group of nurses in Spring 2008 in Baltimore, if the results from the randomized controlled trial are positive, Maryland.

Information will be posted on the website, www.GuidedCare.org. If you are interested in taking the course, please share your contact information with Tracy Novak at 410-614-1932 or tnovak@jhsph.edu.

To support broad dissemination, the innovators are in the process of develop the nurse training program into an interactive, on-line learning experience and is currently identifying partners throughout the nation who would offer the course beginning in 2009.

The innovator is willing to provide materials and tools for adoption by other organizations.
Contact the innovator for additional information.


Contact the Innovator

Note: Innovator contact information is no longer being updated and may not be current.

Chad Boult, MD, MPH, MBA
Health Care Improvement Consultant
Email: chad.e.boult@gmail.com
Phone: (410) 804-8256



Innovator Disclosures

Dr. Boult has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Selected references are listed below; a full list of references is available at http://www.guidedcare.org/program-history-results.asp.

Boyd C, Boult C, Shadmi E, et al. Guided care for multimorbid older adults. Gerontologist. 2007;47(5):697-704. [PubMed]

Wolff JL, Giovannetti ER, Boyd CM, et al. Effects of guided care on family caregivers. Gerontologist. 2010;50(4):459-470. [PubMed]

Marsteller J, Hsu YJ, Reider L, et al. Physician satisfaction with chronic care processes: a cluster-randomized trial of guided care. Ann Fam Med. 2010;8(4):308-315. [PubMed]

Boyd CM, Reider L, Frey K, 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):235-42. [PubMed]

Boult C, Reider L, Leff B, et al. The effect of guided care teams on the use of health services: results from a cluster-randomized controlled trial. Arch Intern Med. 2011;171(5):460-466. [PubMed]

Boult, C, Leff, B, Boyd, CM, et al. A matched-pair cluster-randomized trial of guided care for high-risk older patients. Journal of general internal medicine. 2013;28(5):612-621. [PubMed]

Footnotes

  1. Agency for Healthcare and Research Quality. Preventing disability in the elderly with chronic disease. Research in Action. 2002 April;3. Available at: http://archive.ahrq.gov/research/findings/factsheets/aging/elderdis/elderdis.html.

  2. Thorpe KE, Howard DH. The rise in spending among Medicare beneficiaries: the role of chronic disease prevalence and changes in treatment intensity. Health Aff (Millwood). 2006;25(5):w378-88. [PubMed]

  3. Anderson G. Chronic conditions, expert voices. NIHCM Foundation, January 2002.

  4. Horvath J. Chronic conditions in the US: implications for service delivery and financing. Presentation 2003 Oct 10. Available at: http://archive.ahrq.gov/news/ulp/hicosttele/sess2/horvathtxt.htm.

  5. Wennberg JE, Fisher ES, Goodman DC, et al. Tracking the care of patients with severe chronic illness. The Dartmouth Institute for Health Policy and Clinical Practice: the Dartmouth Atlas of Health Care 2008. Available at:http://www.dartmouthatlas.org/downloads/atlases/2008_Chronic_Care_Atlas.pdf.

  6. Ash AS, Ellis RP, Pope GC, et al. Using diagnoses to describe populations and predict costs. Health Care Financ Rev. 2000;21(3):7-28. [PubMed]

  7. Boyd CM, Reider L, Frey K, 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):235-42. [PubMed]

  8. Wolff JL, Rand-Giovannetti E, Palmer S, et al. Caregiving and chronic care: the guided care program for families and friends. J Gerontol A Biol Sci Med Sci. 2009;64(7):785-91. [PubMed]

  9. Wolff JL, Giovannetti ER, Boyd CM, et al. Effects of guided care on family caregivers. Gerontologist. 2010;50(4):459-470.[PubMed]

  10. Boult C, Reider L, Leff B, et al. The effect of guided care teams on the use of health services: results from a cluster-randomized controlled trial. Arch Intern Med. 2011;171(5):460-466. [PubMed]

  11. Marsteller J, Hsu YJ, Reider L, et al. Physician satisfaction with chronic care processes: a cluster-randomized trial of guided care. Ann Fam Med. 2010;8(4):308-315. [PubMed]

  12. Boult C, Reider L, Frey K, et al. The early effects of “Guided Care” on the quality of health care for multi-morbid older persons. J Gerontol A Biol Med Sci. 2008;63(3):321-7. [PubMed]

  13. Public Law 111-148: The Patient Protection And Affordable Care Act. (124 Stat. 119 through 124 Stat. 1025; Date: March 23, 2010, enacted H.R. 3590). Text from United States Public Laws. Available at: http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf.

Everyone Benefits from Guided Care Nurses

Feedback from patients, primary care doctors, and caregivers, as well as Guided Care Nurses (GCNs) themselves, on the impact of the Guided Care program has been positive. The experiences of participants illustrate key aspects of the program that resonate among patients and providers. In-home assessment of the patient by a GCN expands primary care from an office-based activity to the patient's home. The ongoing relationship that develops between the patient and nurse appears to be an essential element of the program.

One patient, Gerald Altman, Jr., a lawyer who served for more than 30 years in the U.S. Air Force and retired as a full colonel, found that “to have the GCN personally observe the patient in whatever condi tion he is living in, and offer specific advice for improvements, is invaluable. It seems to me that this value could never come from the occasional visit to a doctor's office but certainly is provided in the relationship that exists between the GCN and the patient in this program.”

Participating physicians have also found the program beneficial to their practice of medicine. Dr. Lya Karm, a practicing internist for more than 20 years at Kaiser Permanente Medical Centers in Washington, D.C., was motivated to participate in the Guided Care program, as she felt that the office-based setting was insufficient to meet the needs of patients with multiple medical problems and social needs. “I am very happy we had the chance to participate…The GCN really helps me a lot. Before the GCN joined our team, patients with multiple medical and social problems would come to see me frequently. They also called frequently. And often I felt stuck—frustrated that I wasn't really helping them with what they really needed help with.”

After participating in the program, she found the GCN helpful in supporting patients, freeing up her time to focus on medical issues: “The GCN can really figure out what is going to help each patient and help patients better cope with their illnesses and stressors. As a result, I get less phone calls from patients, as they have learned how to manage their condition.”

The ongoing support has led to more productive medical visits, according to Dr. Karm. “When the patient comes to the office, I am better prepared, as the GCN has given me a heads up as to what is happening with the patient, medically and socially. And the patient is better prepared as a result of the GCN's help: 'What questions do you have for the doctor?' 'What is it you want to talk about?' Overall, it is simply a better visit.”

Internist Dr. Melva Brown at Johns Hopkins Community Physicians at Wyman Park—one of the doctors in the pilot study—found the pilot experience so positive that she volunteered to join the full study. She also finds the program has given her more time to address all the needs of her practice: “Having a GCN has freed up my time, so I can more equitably treat the entire practice. Patients with a lot of problems occupy a disproportionate amount of time. GCN care is a timesaver.”

Her patients are also positive about the program. “Most patients view this as extra access to the doctor; they don't have to go through the red-tape of office maneuvers and telephone menus…It makes access to the doctor a more viable thing and makes for happier patients.”

Dr. Brown notes the GCN ensures treatment changes are “acted upon immediately and efficiently,” thereby reducing communication failures between doctors, nurses, and patients. The program appears to benefit everyone. “As long as we are all on the Web, everyone benefits, particularly the patient.”

Caregiver Carolyn Harp echoed these positive sentiments about the program: “(GCN) Carla Jones has helped me in my role as caregiver, by making herself available. She is a liaison between patient and doctor; when I needed medications or contacts or hospitalization at one point in time, Carla assisted me in getting all of these things done. She has given me a lot of moral support. Knowing I am going to hear from her at least once a month—or more frequently when needed—is a source of strength for me.”

Carla agrees with the importance of being in contact with patients in their home environment. “I get to see the patient where he lives and bring that perspective back to the primary care doctor.”

Ms. Harp found that Carla was of tremendous value when her husband had to be hospitalized. “Carla came out to the house and even helped get him into the car so we could get him to the emergency room. She did all the followup after he was released, including helping us to change to a doctor who we thought might better serve his medical needs. Carla visited him in the hospital and was just generally very supportive.” The GCN “has been there for us on all levels,” concluded Carolyn.

Carla has also found the program rewarding to her professionally: “What I love about the Guided Care program is the freedom, patient advocacy, and creativity it brings to a nurse as a professional. Yes, you're working within a system, and with a doctor, but it's all about patient advocacy. You're advocating for the patient—with the primary care doctor, the specialist, the hospital, empowering the patient to advocate for him or herself. So, patient advocacy is a key component.”

Through regular contact with patients, Carla finds she can identify changes in a patient's ongoing health condition and bring this back to the primary care team for timely response, preventing a potential hospitalization. “By talking to them on a regular basis, I can identify their health care issues. Frequently, I find that a patient is experiencing swelling, fluid overload, shortness of breath, dizziness, or some significant change in their condition, but the doctor didn't know about it. I bring it back to the doctor, it gets addressed in the outpatient setting, and right there we have helped the patient to feel better and avoid a hospitalization.”

Preventing unnecessary hospital stays by empowering the patient and caregiver, coordinating care, and providing the most effective care is what this program aims to do, according to the innovator, geriatrician Dr. Chad Boult. He is Principal Investigator for the Guided Care program and Director of the Roger C. Lipitz Center for Integrated Health Care at the Johns Hopkins Bloomberg School of Public Health. “We will have to wait to see the results from the full study to find out if participants at other sites have similarly positive experiences.”

Care Networks Smooth Transition from Hospital to Nursing Home

Gregory Pawlson MD, MPH , FACP
Senior Medical Analyst, Stevens Lee
Former Executive Vice President, NCQA

Former Member, Innovations Exchange Expert Panel

A growing literature points to transfers from facility to facility or clinician to clinician as a critical juncture for improving quality and reducing waste. A recent study of the Medicare program demonstrates that nearly 20 percent of Medicare patients discharged from a hospital are readmitted within 30 days and nearly half of them have no documented (by claims data at least) contact with the health care system before readmission. 1

Hospital readmission rates from nursing homes have received relatively little attention in the medical literature or in demonstration programs. The data that exists indicate that nursing home patients have very high hospital admission rates with an average of more than 1 hospital bed day per resident per year. Nursing home residents also have high readmission rates—in one study, nearly 50 percent of patients admitted to hospitals from nursing homes were readmitted within a year. 2 Although not all readmissions are preventable, the high cost—both in terms of dollars and impact on the patient—suggests that even a small reduction in preventable admissions or readmissions would be a substantial contribution.

Mary Naylor and her colleagues at the University of Pennsylvania have shown in multiple research demonstration projects that involving nurse care managers—beginning in the hospital and extending beyond discharge—can lower readmission rates. 3 A similar successful model ( Guided Care ) was developed by Chad Boult at Johns Hopkins University to reduce hospital admissions from ambulatory care sites. 4

The innovation, Cooperative Network Improves Patient Transitions Between Hospitals and Skilled Nursing Facilities, Reducing Readmissions and Length of Hospital Stays , is a feasible, effective, and replicable model. The set of interventions developed by Summa Health Care system's “Care Coordination Network” could be amplified further by tying it to other innovations such as the Naylor or Boult models. All of the multiple interventions used in this quality improvement project appear fairly easy to implement by a hospital, health plan, or even a large integrated medical group.

An area not addressed by the innovation is reimbursement disincentives to reduce admissions and readmissions. Health plans including Medicare Advantage that cover both skilled care and nursing home care have some financial incentive to reduce readmissions. But, hospitals and nursing homes often benefit financially from having a high volume of hospital admissions and readmissions. Given the still-dominant Medicare fee-for-service sector, it is often difficult to support innovations of this type that clearly would benefit society and individual patients. Payment modifications involving bundled payments or nonpayment for avoidable readmissions might substantially increase the number of entities using innovations like this one.

References

1 Quality Matters: Hospital Readmissions, The Commonwealth Fund, Vol. 29, March/April 2008.

2 Lewis MA, Leake B, Clark V, et al. Changes in case mix and outcomes of readmissions to nursing homes between 1980 and 1984. Health Serv Res. 1990;24(6):713-28. [PubMed]

3 Naylor MD. Transitional care for older adults: a cost-effective model. LDI Issue Brief. 2004;9(6):1-4. [PubMed]

4 Aliotta SL, Grieve K, Giddens JF, et al. Guided care: a new frontier for adults with chronic conditions. Prof Case Manag. 2008;13(3):151-8; quiz 159-60. [PubMed]


Disclosure Statement: Dr. Pawlson has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.

Funding Sources

Agency for Healthcare Research and Quality
National Institute on Aging
John A Hartford Foundation
Jacob and Valeria Langeloth Foundation
Kaiser Permanente-Mid-Atlantic States
Johns Hopkins Bloomberg School of Public Health - Roger C. Lipitz Center for Integrated Health Care
Johns Hopkins HealthCare

Developers

Johns Hopkins Bloomberg School of Public Health

Baltimore, MD

Comments

By The Editorial Team on
Readers may be interested in this article from the NY Times health page about the need for a new model of geriatrics care. The article describes the Guided Care Nursing program as one example and features comments from Dr. Boult.The article is available at http://www.nytimes.com/2008/12/30/health/30bbox.html?ref=health

By Maurice J. on
Could the guided care nursing model to younger populations with chronic conditions? Do you have plans to do so?

By Laura M. on
How much does the guided care model in actual practice differ from primary care delivery with intensive nurse practitioner involvement?

By Kenneth Finegold on
Is reimbursement for guided care nursing services limited to the national Medicare Medical Home Demonstration?

By Shannon F. on
Is there private insurance interest in reimbursement for this kind of care for either elderly or non-elderly populations?

By Mitchell Sullivan on
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 which lead to unnecessary healthcare expenditures. Policymakers in Congress need to undertstand this to enable funding to support this change, as most practices, particularly FQHCs like ours, will not be able to assume the expense of these caregivers without some additional funding.

By A. Dievler on
Aside from clinical factors such as chronic disease, what other characteristics make some patients better candidates for guided care nursing than others?

By Kristine S on
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?

By Susan H. on
Could 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?

By Jane C. on
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?

By Chris on
Could 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?

By Christopher S on
What community resources has your innovation more heavily tapped? How have you been able to facilitate their access?

By SJ Schneider on
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. Modifying an off-the-shelf EHR is not always easy …Could you briefly tell me what would be involved?

By Martha F. on
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. Could you briefly describe the central characteristics of the Web-based EHR that are needed to support this program?

By William H on
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?

By Debra D. on
Does this program actually increase health care quality or improve outcomes?

By Katharine G on
Could you describe the kinds of patients and caregivers who have so far been involved with Guided Care Nursing? What do they like most about the program? Like least?

By Josh N. on
You mentioned that patient-reported quality of care was higher using Guided Care nursing. Have you measured quality of care in other ways?

By Christine L. on
Are there chronic conditions that Guided Care Nursing has been particularly successful in addressing?

By Maria M. RN on
Faith Community or Parish Nurses provide this care already when all stakeholders in the process (primary care MDs, hospitals, rehab centers, etc.) are aware of our role and willing to work with us.
Original Publication: 10/17/08

Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last Updated: 07/30/14

Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: 05/29/14

Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read Health Care Innovations Exchange Disclaimer.

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