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

ABSTRACT 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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    • "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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    • "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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    • "Two studies emphasised the value of patient empowerment through knowledge and education and included the use of electronic medical records in the intervention, with varying degrees of success with their elderly patients. The Care Transitions Intervention's (Parry et al. 2003) patient-driven personal health record was used by only half of the participants; the Guided Care intervention's electronic health record provided caregivers with patient assessment information and best practices guidelines and was considered essential to the programme (Boyd et al. 2007). Caregiver involvement was acknowledged as an important aspect of these interventions; all but one of the studies (n = 9) provided caregivers with education and support in the navigation intervention. "
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