Guided Care for Multimorbid Older Adults

TLDR

The study aimed to test the feasibility of a Guided Care model designed to improve quality of life and resource efficiency for older adults with multimorbidity. Guided Care integrates seven chronic‑care innovations and is delivered by a trained nurse who uses a customized electronic health record to assess, plan, monitor, coach, coordinate, and support 50–60 multimorbid patients in collaboration with primary‑care physicians. A one‑year pilot in a community primary‑care practice found Guided Care feasible and acceptable to physicians, patients, and caregivers, and suggested it could enhance quality of life and health‑care efficiency if proven in a controlled trial.

Abstract

Purpose: The purpose of this study was to test the feasibility of a new model of health care designed to improve the quality of life and the efficiency of resource use for older adults with multimorbidity. Design and Methods: Guided Care enhances primary care by infusing the operative principles of seven chronic care innovations: disease management, self-management, case management, lifestyle modification, transitional care, caregiver education and support, and geriatric evaluation and management. To practice Guided Care, a registered nurse completes an educational program and uses a customized electronic health record in working with two to five primary care physicians to meet the health care needs of 50 to 60 older patients with multimorbidity. For each patient, the nurse performs a standardized comprehensive home assessment and then collaborates with the physician, the patient, and the caregiver to create two comprehensive, evidence-based management plans: a Care Guide for health care professionals, and an Action Plan for the patient and caregiver. Based in the primary care office, the nurse then regularly monitors the patient's chronic conditions, coaches the patient in self-management, coordinates the efforts of all involved health care professionals, smoothes the patient's transitions between sites of care, provides education and support for family caregivers, and facilitates access to community resources. Results: A 1-year pilot test in a community-based primary care practice suggested that Guided Care is feasible and acceptable to physicians, patients, and caregivers. Implications: If successful in a controlled trial, Guided Care could improve the quality of life and efficiency of health care for older adults with multimorbidity.