Guided Care for Multimorbid Older Adults

Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
The Gerontologist (Impact Factor: 3.21). 11/2007; 47(5):697-704.
Source: PubMed


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.
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.
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.
If successful in a controlled trial, Guided Care could improve the quality of life and efficiency of health care for older adults with multimorbidity.

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Available from: Jennifer L Wolff, Oct 05, 2015
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    • "The goals of primary care should include the enhancement of patients' functional status, minimising symptoms, disability and pain and prolonging life through secondary prevention (American Expert Panel, 2012). Yet despite these admirable goals, many qualified health care professionals report that they feel inadequately prepared to effectively manage multimorbidity (Boyd et al., 2007) and there is a reliance on single disease clinical pathways and guidelines which have not been tested in a multimorbid context. Clinical evidence and guidelines most often focus on a single disease and most randomised controlled trials exclude the elderly and those with multiple conditions (Barnett et al., 2012). "
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    ABSTRACT: The rise in prevalence of chronic diseases has become a global healthcare priority and a system wide approach has been called for to manage this growing epidemic. Whilst healthcare reform to tackle the scale of chronic disease and other long term conditions is still in its infancy, there is an emerging recognition that in an ageing society, people often suffer from more than one chronic disease at the same time. Multimorbidity poses new and distinct challenges and was the focus of a global conference held by the Organization of Economic Cooperation and Development (OECD) in 2011. Health education was raised as requiring radical redesign to equip graduates with the appropriate skills to face the challenges ahead. We wanted to explore how different aspects of multimorbidity were addressed within pre-registration nurse education and held an international (United Kingdom-Sweden) nurse workshop in Linköping, Sweden in April 2013, which included nurse academics and clinicians. We also sent questionnaire surveys to final year student nurses from both countries. This paper explores the issues of multimorbidity from a patient, healthcare and nurse education perspective and presents the preliminary discussions from the workshop and students' survey.
    Nurse Education Today 05/2014; DOI:10.1016/j.nedt.2014.05.006 · 1.36 Impact Factor
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    • "Nurse care coordination is an evolving registered nurse role included in HCH initiatives. Specially trained nurses working within primary care teams have effectively improved care for older adults by coordinating care across care settings and providers (Boyd et al., 2007). Numerous studies indicate that nurses are effective in providing care coordination and self-management support in primary "
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    ABSTRACT: Care coordination within Health Care Homes (HCHs) is an evolving registered nurse role. The purpose of this study was to identify factors influencing nurse care coordination. The aims are to 1) describe the characteristics of patients perceived by nurse care coordinators (NCCs) to benefit from care coordination and to 2) describe interventions judged by NCCs to be most effective in caring for patients with complex chronic care needs. This study was an analysis of existing data using a qualitative descriptive design. Experienced NCCs from various practice settings participated in a focus group. Data were analyzed using content analysis. Findings indicate the importance of the cumulative impact of complex health problems, limited social support, culture and language on patients needing care coordination. Effective interventions are focused on providing holistic, relationship-based care. The identification of contextual factors juxtaposed to complex chronic health conditions holds promise as a powerful indicator of individuals needing targeted, individualized interventions.
    Applied nursing research: ANR 03/2014; 28(1). DOI:10.1016/j.apnr.2014.03.004 · 0.73 Impact Factor
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    • "Patients with multimorbidity report poor physician-patient communication, worse interpersonal treatment, and lack of care coordination [7,8]. To meet these challenges, care management programs are emerging, aiming to provide better self management support and care coordination [9,10]. "
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    ABSTRACT: Targeting patients for multimorbid care management interventions requires accurate and comprehensive assessment of patients' need in order to direct resources to those who need and can benefit from them the most. Multimorbid patient selection is complicated due to the lack of clear criteria - unlike disease management programs for which patients with a specific condition are identified. This ambiguity can potentially result in inequitable selection, as biases in selection may differentially affect patients from disadvantaged population groups. Patient selection could in principal be performed in three ways: physician referral, patient screening surveys, or by statistical prediction algorithms. This paper discusses equity issues related to each method. We conclude that each method may result in inequitable selection and bias, such as physicians' attentiveness or familiarity, or prediction models' reliance on prior resource use, potentially affected by socio-cultural and economic barriers. These biases should be acknowledged and dealt with. We recommend combining patient selection approaches to achieve high care sensitivity, efficiency and equity.
    International Journal for Equity in Health 08/2013; 12(1):70. DOI:10.1186/1475-9276-12-70 · 1.71 Impact Factor
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