The Effect of Guided Care Teams on the Use of Health Services Results From a Cluster-Randomized Controlled Trial

Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Room 693, Baltimore, MD 21205, USA.
Archives of internal medicine (Impact Factor: 17.33). 03/2011; 171(5):460-6. DOI: 10.1001/archinternmed.2010.540
Source: PubMed


The effect of interdisciplinary primary care teams on the use of health services by patients with multiple chronic conditions is uncertain. This study aimed to measure the effect of guided care teams on multimorbid older patients' use of health services.
Eligible patients from 3 health care systems in the Baltimore, Maryland-Washington, DC, area were cluster-randomized to receive guided care or usual care for 20 months between November 1, 2006, and June 30, 2008. Eight services of a guided care nurse working in partnership with patients' primary care physicians were provided: comprehensive assessment, evidence-based care planning, monthly monitoring of symptoms and adherence, transitional care, coordination of health care professionals, support for self-management, support for family caregivers, and enhanced access to community services. Outcome measures were frequency of use of emergency departments, hospitals, skilled nursing facilities, home health agencies, primary care physician services, and specialty physician services.
The study included 850 older patients at high risk for using health care heavily in the future. The only statistically significant overall effect of guided care in the whole sample was a reduction in episodes of home health care (odds ratio, 0.70; 95% confidence interval, 0.53-0.93). In a preplanned analysis, guided care also reduced skilled nursing facility admissions (odds ratio, 0.53; 95% confidence interval, 0.31-0.89) and days (0.48; 0.28-0.84) among Kaiser-Permanente patients.
Guided care reduces the use of home health care but has little effect on the use of other health services in the short run. Its positive effect on Kaiser-Permanente patients' use of skilled nursing facilities and other health services is intriguing. Trial Registration Identifier: NCT00121940.

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Available from: Jennifer L Wolff, Oct 05, 2015
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    • "Hospital readmission rates from the SHHC setting are approximately 25%, with most occurring within 2–4 weeks after hospital discharge (Anderson, Hanson, DeVilder, & Helms, 1996;Ashton et al., 1999). Although interventions exist to improve care transitions from hospital to home (Arbaje et al., 2010;Boult et al., 2011;Coleman, Parry, Chalmers, & Min, 2006;Jack et al., 2009;Naylor et al., 1999), given that re-hospitalization rates from SHHC settings remain high (Madigan et al., 2012;Rosati & Huang, 2007), interventions that account for the complexity of the hospital to SHHC transitions are still needed. "
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    ABSTRACT: Older adults discharged from the hospital to skilled home health care (SHHC) are at high risk for experiencing suboptimal transitions. Using the human factors approach of shadowing and contextual inquiry, we studied the workflow for transitioning older adults from the hospital to SHHC. We created a representative diagram of the hospital to SHHC transition workflow, we examined potential workflow variations, we categorized workflow challenges, and we identified artifacts developed to manage variations and challenges. We identified three overarching challenges to optimal care transitions-information access, coordination, and communication/teamwork. Future investigations could test whether redesigning the transition from hospital to SHHC, based on our findings, improves workflow and care quality.
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    • "The HCH, a patient-centered care model, places an emphasis on care coordination and self-management support rather than disease management. Registered nurses, functioning as nurse care coordinators (NCCs), have proven to be critical members of interdisciplinary care teams in improving patient outcomes (Boult et al., 2011; Boyd et al., 2009); however, little is known about patients who may benefit from care coordination. There is a need to identify the characteristics of patients who benefit from care coordination and the effective interventions used by experienced NCCs. "
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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.
    Full-text · Article · Mar 2014 · Applied nursing research: ANR
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    • "The effectiveness of the complete CCM [30], within a population of elderly people that was not defined in terms of any specific disease, was evaluated in a study on the Guided Care model [31]. Effects on outcomes for elderly people and their caregivers [32], quality of care [33], and costs [34] were studied. Patient activation was improved, while caregiver burden was diminished [32]. "
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    ABSTRACT: Background Ongoing growth in health care expenditures and changing patterns in the demand for health care challenge societies worldwide. The Chronic Care Model (CCM), combined with classification for care needs based on Kaiser Permanente (KP) Triangle, may offer a suitable framework for change. The aim of the present study is to investigate the effectiveness of Embrace, a population-based model for integrated elderly care, regarding patient outcomes, service use, costs, and quality of care. Methods/Design The CCM and the KP Triangle were translated to the Dutch setting and adapted to the full elderly population living in the community. A randomized controlled trial with balanced allocation was designed to test the effectiveness of Embrace. Eligible elderly persons are 75 years and older and enrolled with one of the participating general practitioner practices. Based on scores on the INTERMED-Elderly Self-Assessment and Groningen Frailty Indicator, participants will be stratified into one of three strata: (A) robust; (B) frail; and (C) complex care needs. Next, participants will be randomized per stratum to Embrace or care as usual. Embrace encompasses an Elderly Care Team per general practitioner practice, an Electronic Elderly Record System, decision support instruments, and a self-management support and prevention program – combined with care and support intensity levels increasing from stratum A to stratum C. Primary outcome variables are patient outcomes, service use, costs, and quality of care. Data will be collected at baseline, twelve months after starting date, and during the intervention period. Discussion This study could provide evidence for the effectiveness of Embrace. Trial registration The Netherlands National Trial Register NTR3039
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