DorlandHealth

Richard Scott

A new program in its third year of testing shows promising patient improvement rates for two segments of the population that together incur the bulk of health care spending—the elderly and those with multiple chronic conditions.

The Guided Care program, established at Johns Hopkins University in Baltimore, Md., is now running in pilot programs in seven Washington, D.C., and Baltimore-area community-based primary care practices, and its early adoptees have witnessed reduced admission rates, lower costs and increased patient satisfaction with the “frail elderly” population it serves.

“Guided Care takes the patient and the patient’s preferences and goals into account,” says Carol Groves, the director of senior services with Kaiser Permanente Mid-Atlantic States, where three pilot programs have recently passed an 18-month testing threshold. With a patient-centered focus and regular intervention by a specially trained nurse, Kaiser’s Guided Care implementation has resulted in reduced hospital admissions and hospital days and, more significantly, a “huge difference” in the utilization of skilled nursing facilities. “It seems that patients have the confidence to go home from the hospital vs. being admitted to a skilled nursing facility,” says Groves.

The Guided Care program shares similarities with the burgeoning medical home model, which situates a multidisciplinary team around a patient’s care process, and with Guided Care a registered nurse acts as the primary point person in the patient’s care as well as the direct patient liaison. This nurse, who has received training in geriatrics, manages a caseload of 50 to 60 patients who have been identified previously as suitable patients through predictive modeling. The initial point of contact comes by way of an in-house assessment. The nurse then meets with the primary treating physician and together they craft a specified plan of care based on the information gathered from the face-to-face meeting.

“What I really like about this model,” says Groves, “is that the nurse actually sits on the health care team with the physician. Building that relationship with the health care team, we found, is really critical.”

After consulting with the physician, the nurse creates an individualized “care guide” and follows that up with another face-to-face meeting with the patient to review the guide, which contains the patient’s goals, a background of conditions, current medications and—in what is a simple but profound inclusion—the nurse’s direct contact information. This helps spur patient involvement, says Groves, because the patient knows the nurse has “immediate access to the physician.”

Monthly coaching calls follow, where goals are monitored and the patient’s progress discussed. Should the patient require admission to a hospital or SNF, the nurse will visit the patient and share the care guide with the attending physician and nurses.

“I think of it as a super case management program, if you will,” says Groves. “What the nurses tell me is that they establish a relationship over a period of time. They develop trust with the patient.”

Encouraging this population toward improved adherence, proper utilization and more complete wellness holds the potential for drastic cost-savings across health care. Patient with multiple chronic conditions cost roughly seven times as much as patient with one chronic condition, according to the Agency for Healthcare Research and Quality, and the elderly consume about 36 percent of personal health care expenses despite comprising roughly one-third—or 13 percent—of that number of the U.S. population. Simply put, “a much higher proportion of the elderly than the non-elderly have expensive chronic conditions,” according to the AHRQ website. One-quarter of Medicare patients account for 85 percent of total spend.

Though Kaiser has not formally published its results, Groves cites a reduction of more than 40 percent of SNF admissions in the Guided Care group compared to a control group. Part of this reduction may have to do with readmissions. Once a patient is discharged, the Guided Care nurse visits the patient at his or her home within 48 hours. “This is key,” says Groves. “So many times medications aren’t correct. It’s confusing to the population under 65, but for the population over 65 it becomes so much more confusing.

Guided Care has begun to show true worth at a vital time, as baby boomers continue to crest the plateau of 65. The American Nurses Association offers a training and certification program for this specialty, which shows no signs of abating. Kaiser, for one, has plans to expand its model. “We recognize that there aren’t going to be enough geriatricians to take care of this aging population, so it’s going to rest with primary care,” says Groves. “This is a model that really support primary care and their management of the frail elderly.”