Kathleen Walsh Piercy, PhD, Editor
Vol. 47, No. 5, 697–704
Copyright 2007 by The Gerontological Society of America
Guided Care for Multimorbid Older Adults
Cynthia M. Boyd, MD,1,2Chad Boult, MD,1,2Efrat Shadmi, RN, PhD,3
Bruce Leff, MD,1,2Rosemarie Brager, CRNP, PhD,4
Linda Dunbar, RN, PhD,5Jennifer L. Wolff, PhD,1,2
and Stephen Wegener, PhD6
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.
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
smoothes the patient’s transitions between sites of
care, provides education and support for family care-
givers, 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
Implications: If successful in a controlled
trial, Guided Care could improve the quality of life and
Key Words: Chronic disease, Nursing,
Primary care, Multimorbidity
None of us received corporate financial support, consultantships,
speaker arrangements, company holdings, or patents related to this
research or to the materials described in this article. Johns Hopkins
HealthCare LLC contributed funding and administrative support for the
Guided Care nurse, the development of the customized electronic health
record, and the analysis of claims data. Johns Hopkins Community
Physicians contributed access to patients, the efforts of the primary care
physicians, and office space and equipment at the community-based
primary care practice. The Roger C. Lipitz Center for Integrated Health
Care contributed funding and administrative support. Cynthia M. Boyd
was supported by the John A. Hartford Foundation Center of Excellence
and the Johns Hopkins Bayview Scholars at the Center for Innovative
Medicine at the Johns Hopkins Bayview Medical Center. We retained
full scientific autonomy in the preparation of this article and the design
of the model of care.
We appreciate the administrative assistance of Adriane King, MA,
and contributions to the Guided Care model and this article by Katherine
Frey, MPH, and Lisa Semanick, MHS. We are grateful to Erin Rand-
Giovannetti for her work on the caregiver intervention design.
Address correspondence to Cynthia Boyd, MD, MFL Building,
7th Floor, 5200 Eastern Avenue, Baltimore, MD 21224. E-mail: cyboyd@
1Division of Geriatric Medicine and Gerontology, Department of
Medicine, Johns Hopkins School of Medicine, Baltimore, MD.
2Roger C. Lipitz Center for Integrated Health Care, Department of
Health Policy and Management, Johns Hopkins Bloomberg School of
Public Health, Baltimore, MD.
3The Cheryl Spencer Department of Nursing, Faculty of Social
Welfare and Health Studies, University of Haifa, Israel.
4Johns Hopkins School of Nursing, Baltimore, MD.
5Johns Hopkins HealthCare LLC, Glen Burnie, MD.
6Department of Physical Medicine and Rehabilitation, Johns
Hopkins University School of Medicine, Baltimore, MD.
Vol. 47, No. 5, 2007697
The present system of American health care is
a loose array of
physician groups, hospitals, and other health care
organizations [that] operate as silos, often providing
care without the benefit of complete information about
the patient’s condition, medical history, services pro-
vided in other settings, or medications prescribed by
other clinicians ... It is not surprising, then, that
studies of patient experience document that the health
system for some is a ‘‘nightmare to navigate.’’
(Institute of Medicine, 2001, p. 4)
This system often succeeds in meeting the episodic
needs of healthy people who experience acute illnesses
and injuries, but it often often fails older adults who
have several chronic conditions (multimorbidity) and
complex care needs. The mismatch between the acute
care orientation of the delivery system and the chronic
care needs of this vulnerable population induces many
failures: medical error, underdiagnosis, inconsistent
monitoring of chronic conditions, lack of attention to
the preferences of individual patients and their care-
givers, insufficient health education and encouragement
for patients and unpaid caregivers to participate in
their own health care (Holman & Lorig, 2000), ad-
verse drug reactions (Gandhi et al., 2003; Gurwitz
et al., 2003; Juurlink, Mamdani, Kopp, Laupacis, &
Redelmeier, 2003), duplication of some health-related
services, inappropriate omission of others, and pre-
ventable injuries occurring soon after discharge from
hospitals (Forster, Murff, Peterson, Gandhi, & Bates,
These failings produce predictable results: poor
quality of health care (McGlynn et al., 2003), low
levels of satisfaction, and very high costs. Spending
for the 62% of older Americans with multimorbidity
consumes 96% of the Medicare budget, and beneficia-
ries with four or more chronic conditions are 99 times
more likely to have potentially preventable hospital
admissions for ‘‘ambulatory care sensitive conditions’’
than beneficiaries with none (Wolff, Starfield, &
Anderson, 2002). Physicians feel inadequately prepared
to care for chronically ill patients (Darer, Hwang,
Pham, Bass & Anderson, 2004). The physical and
emotional burden on the unpaid caregivers of chron-
ically ill older people is associated with depressive
symptoms, poor health, and increased risk of pre-
mature mortality (Schulz & Beach, 1999).
To bridge the gap between society’s growing
need for high-quality chronic care and its present
fragmented, acute-care-oriented delivery system, re-
searchers have proposed new conceptual models for
improving chronic care. The Chronic Care Model
posits that redesign of the delivery system, enhanced
decision support, improved clinical information sys-
tems, support for self-management, and better access to
community resources will improve outcomes for people
with chronic conditions (Bodenheimer, Wagner, &
Grumbach, 2002). In support of the chronic care model,
studies have shown that innovations in these domains
can improve clinical and/or financial outcomes in
outpatient settings (Boult et al., 2001; Cohen et al.,
2002; Phelan, Williams, Penninx, LoGerfo, & Leveille,
2004; Reuben, Frank, Hirsch, McGuigan, & Maly,
1999; Sommers, Marton, Barbaccia, & Randolph,
2000; Unutzer et al., 2002), in hospitals (Landefeld,
Palmer, Kresevic, Fortinsky, & Kowal, 1995), in emer-
gency departments (Miller, Lewis, Nork, & Morley,
1996), in nursing homes (Joseph & Boult, 1998; Kane,
Homyak, Bershadsky, Flood, & Zhang, 2004; Reuben,
Schnelle, et al., 1999), in the home (Stuck, Egger,
Hammer, Minder, & Beck, 2002), and during tran-
sitions between sites of care (Naylor et al., 1999).
Likewise, interventions that focus on the caregivers of
individuals with dementia have delayed nursing home
placement (Mittelman, Ferris, Shulman, Steinberg, &
Levin, 1996) and improved caregivers’ well-being
(Mittelman, Roth, Coon, & Haley, 2004). Compre-
hensive multidisciplinary interventions for chronically
ill older adults have reduced caregiver burden (Weuve,
Boult, & Morishita, 2000). A six-session, small-group
chronic disease self-management course, led by trained
lay leaders, has helped older adults with multimor-
bidity set and pursue personal goals for their health
and, thereby, improve their quality life and reduce their
use of hospitals (Lorig et al., 2001). Table 1 summarizes
the nature and effects of seven successful community-
based innovations in chronic care, each of which
addresses one component of the Chronic Care Model
(see Figure 1). As shown in Table 2, each innovation
addresses only a subset of the challenges faced by older
people with chronic conditions; rarely have more than
two of these innovations been combined in practice
(Eng, Pedulla, Eleazer, McCann, & Fox, 1997;
Newcomer, Harrington, & Kane, 2000).
To improve this population’s quality of life and
efficiency of resource use, we enhanced their primary
care by infusing the operative principles of the seven
chronic care innovations summarized in Table 1. In the
enhanced model, called Guided Care, a registered nurse
completes an educational program and then uses a
customized electronic health record (EHR) in working
with two to five primary care physicians to meet the
complex needs of 50 to 60 older patients with mul-
timorbidity. The Guided Care nurse (GCN) is based in
the primary care office. The GCN’s eight clinical activ-
ities, described below, are guided by scientific evidence,
by patients’ priorities, and by the EHR.
Using standardized instruments, the GCN performs
an initial assessment of the patient’s medical, functional,
cognitive, affective, psychosocial, nutritional, and envi-
ronmental status during a home visit. The instruments
include inventories of impairment in instrumental
activities of daily living and activities of daily living;
the Nutrition Screening Initiative checklist (White
et al., 1992); the Mini-Mental State Examination
(Folstein, Folstein, & McHugh, 1975); the Get Up &
Go test (Podsiadlo & Richardson, 1991); the Geriatric
Depression Scale (Yesavage et al., 1982); the CAGE
alcoholism scale (Mayfield, McLeod, & Hall, 1974);
and screening questions for hearing impairment, falls,
and urinary incontinence. The GCN also asks the
patient to identify his or her highest priorities for
optimizing health and quality of life.
The EHR merges these individual assessment data
with evidence-based best practice recommendations to
create a preliminary Care Guide that lists medical and
behavioral plans for managing and monitoring each of
Table 1. Successful Innovations in Health Care for Older People With Chronic Conditions
Outpatient geriatric evaluation
Nurse, SW, physician, physical
Nurse, SW, physician
" function, $ (Reuben, Frank, et al., 1999)
" function, $, satisfaction with care
(Cohen et al., 2002)
# depression, caregiver burden; " function
(Boult et al., 2001)
" quality of life, function, satisfaction
with care (Ofman et al., 2004;
Unutzer et al., 2002)
" health, # hospital days (Lorig et al., 2001)
# hospital days, $, disability (Phelan et al.,
# $ (Boult et al., 2000)
# hospital admission, days, $ (Naylor
et al., 1999)
# hospital readmissions, $ (Rich et al., 1995)
# nursing home admissions (Mittelman
et al., 1996)
Nurse, SW, physician
Disease managementNurse, physician
Chronic disease self-management
Health enhancement program
Advance practice nurse
Nurse, dietician, SW, physician
SW, psychologist Caregiver education and support
Note: SW ¼ social worker; $ ¼ costs.
Figure 1. Guided Care and the chronic care model. Source: Wagner, E. H. (1998). Chronic disease management: What will it take
to improve care for chronic illness? Effective Clinical Practices, 1, 2–4. Reproduced with permission. The Improving Chronic Illness
Care program is supported by The Robert Wood Johnson Foundation, with direction and technical assistance provided by Group
Health’s MacColl Institute for Healthcare Innovation.
Vol. 47, No. 5, 2007699
the patient’s chronic conditions. The GCN and the
primary care physician then personalize this prelimi-
nary Care Guide to align it with the unique circum-
stances of the individual patient. The GCN then
discusses the preliminary Care Guide with the patient
and caregiver and modifies it further for consistency
with their preferences, priorities, and intentions. The
final Care Guide provides all involved health care
professionals with a concise summary of the patient’s
status and plans; the GCN updates it regularly. A
patient-friendly version, called My Action Plan, is
written in lay language and displayed prominently in
the patient’s home.
Chronic Disease Self-Management (CDSM)
The GCN promotes the patient’s self-efficacy in
managing chronic conditions by referring him or her to
a free, local, 15-hr (six-session) CDSM course (Lorig &
Holman, 2003) that is led by trained lay people and
supported by the GCN. In this course, developed at
Stanford University, the patient learns to refine and
implement the Action Plan. Reinforced by simple, easy-
to-read schedules and reminders, the Action Plan
facilitates the patient’s steps toward healthy eating,
sleeping, exercising, and use of medication, as well as
self-monitoring, using the health care system, and
avoiding tobacco and alcohol abuse.
With reminders from the EHR, the GCN monitors
each patient at least monthly by telephone to detect and
address emerging problems promptly. When problems
appear, the GCN discusses them with the primary care
physician and takes appropriate action. On weekdays,
the GCN is directly accessible by telephone to the
patient and caregiver for questions and concerns.
In conjunction with the monthly monitoring calls,
the GCN uses motivational interviewing (Bennett et al.,
2005) to facilitate the patient’s participation in care
and to reinforce adherence to the Action Plan. This
coaching interaction is based on the Transtheoretical
Model of Change (Prochaska & DiClemente, 1984),
which recognizes that individuals are at various stages
in making health behavior changes. GCNs are trained
in motivational interviewing principles and strategies
(Rollnick, Mason, & Butler, 1999) and use them to
identify patient preferences, assist the patient in
developing and maintaining healthy behaviors, and
encourage the patient and caregiver to participate in
CDSM classes. During coaching sessions, the GCN
expresses empathy, clarifies discrepancies between
current behavior and health goals, avoids arguing,
and supports self-efficacy.
Coordinating Transitions Between Sites and
Providers of Care
The GCN coordinates the efforts of all of the health
care professionals who treat Guided Care patients in
emergency departments, hospitals, rehabilitation facil-
ities, offices, nursing homes, and at home. Each patient
Table 2. Needs Assessment by Innovations in Chronic Care
XXXX XXXXXX XX XXXX XX
Source: Reproduced with permission from Wolff, J. L., & Boult, C. (2005). Moving beyond round pegs and square holes: Restructuring
Medicare to improve chronic care. Annals of Internal Medicine, 143, 439–445.
Note: X ¼ addresses need partially; XX ¼ addresses need thoroughly.
is encouraged to contact his or her GCN before or
during admissions to emergency departments and
hospitals. The GCN does not usurp the duties of other
professionals but instead provides each with current
information (the patient’s Care Guide), explains the
GCN role, visits the patient during stays in institutions,
and helps plan and execute follow-up. Thus, the GCN
smoothes the patient’s path between all sites and pro-
viders of care, focusing most intensively on transitions
through hospitals, and keeps the primary care physi-
cian informed of the patient’s current status.
Educating and Supporting Caregivers
For the family or other unpaid caregivers of patients
with functional impairment or difficulty with health
care tasks, the GCN offers individual and group
assistance: initial assessment, a free self-management
course for caregivers (10 hr over 6 weeks), monthly
support group meetings, and ad hoc telephone
Accessing Community Resources
The GCN facilitates access to community resources
to meet the patient’s and the caregiver’s needs. The
GCN may suggest, for example, that the patient or
caregiver contact a transportation service, Meals on
Wheels, the Area Agency on Aging, or the local
Alzheimer’s Association. Table 3 shows a GCN’s
allocation of time among these activities.
The GCN uses a laptop computer to access a secure,
custom-designed, Web-based EHR to conduct initial
assessments, check for potential drug interactions,
create Care Guides, monitor and coach patients, and
document clinical encounters. The EHR, used only by
the GCN, provides printed reports that supplement the
Guided Care patient’s other medical records.
Identifying the patients who are most likely to
benefit from Guided Care (i.e., those with multi-
morbidity, complex health care needs, and high
expenditures for health care) is crucial to the cost
effectiveness of Guided Care. Although clinicians are
capable of identifying patients with multimorbidity,
electronic predictive modeling, which uses administra-
tive data and diagnoses from insurance claims to
estimate a patient’s future health care needs, can iden-
tify such patients more consistently and efficiently
(Institute for Health Policy Solutions, 2005). Insurers or
provider organizations analyze the previous year’s
insurance claims using the hierarchical condition cat-
egory predictive model (Ash et al., 2000) to select for
Guided Care the 25% of older patients in primary care
panels who have the highest estimated need for
complex health care in the future. No high-risk patients
are excluded because of a condition (e.g., dementia) or
place of residence (e.g., nursing home), although some
are unable to participate in CDSM.
Qualities that make registered nurses well suited to
becoming GCNs include proficiency in communica-
tion, flexibility in complex problem solving, cultural
competence, comfort with interdisciplinary team care,
experience in geriatric and community nursing, and
enthusiasm for coaching patients and caregivers in self-
management. To prepare for the GCN role, nurses
complete an educational program that emphasizes skill
development through interactive role-playing in simu-
lated situations and is supplemented by readings and
brief lectures. Topics include using the EHR, compre-
hensive assessment and planning, monitoring, coaching
to enhance self-management by patients and caregivers,
transitional care, cultural competence, communication
with other health care professionals, elder abuse,
health insurance, and community resources.
Groups of primary care physicians (general internists
and family physicians) that together care for at least
400 older (aged 65þ) patients are likely to have at least
50 to 60 older patients with multimorbidity who could
benefit from Guided Care and would like to receive it.
To initiate Guided Care, a practice provides an onsite
office and integrates the GCN into the work flow of the
physicians and the office staff over 3 to 4 months.
During this integration process, the GCN observes the
physicians’ practice styles and patient interactions;
discusses cases with them; reads medical records;
becomes acquainted with the office staff members’
roles and interactions; learns the office’s operating
procedures; develops an identity as a member of the
office staff; and becomes familiar with local community
resources, such as the Area Agency on Aging, senior
centers, hospitals, and other health care providers. The
physicians introduce the GCN to their patients, and the
GCN–physician dyads develop patterns for communi-
cating about their patients.
From October 2003 to September 2004, we tested the
feasibility of implementing a pilot version of Guided
Care that included six of its eight core processes. The
pilot version excluded CDSM and caregiver education
and support because of budgetary constraints. A
registered nurse recruited from the local community
was trained and introduced into the practice of two
general internists at a nonacademic primary care
practice in urban Baltimore.
Table 3. Allocation of Time in a Typical Week of a
Guided Care Nurse
Coordinating transitions between sites and
providers of care
Updating the electronic health record
Educating and supporting caregivers
Accessing community resources
Communicating with primary care physicians
Supporting the chronic disease self-management
Vol. 47, No. 5, 2007701
Using predictive modeling software, we identified
these internists’ older patients who had multimorbidity
and were likely to benefit from Guided Care. The GCN
worked with the two physicians and their office staff
to assess and plan care for these patients, and then to
provide them with monitoring, coaching, care co-
ordination, and access to community resources.
As reported elsewhere (Sylvia et al., 2006), the
patients identified for this pilot test of Guided Care had
multimorbidity (M¼3.0 chronic conditions per person)
and functional disability (36% had difficulty perform-
ing activities of daily living, 58% had difficulty
performing instrumental activities of daily living), and
they had generated high insurance expenditures for
health care (M ¼ $22,800 per person per year).
Integrating the GCN into the work flow of the office
practice required several months of orientation and
problem solving. The support of the physicians, who
were initially somewhat skeptical about Guided Care,
was essential in developing effective teamwork in the
In informal debriefings at the end of the pilot year,
the physicians expressed appreciation and enthusiasm
for Guided Care. They observed that the GCN had
improved the quality of the patients’ chronic care,
especially the communication and coordination among
providers. They estimated that the time they had
devoted to communicating with the GCN had been
offset by reductions in the time they had to devote to
unreimbursed tasks, such as requesting referrals,
responding to telephone calls, and coordinating care
with other providers. Both physicians expressed a
strong desire to work with a GCN again in the future.
Anecdotal reports indicated that the patients and
families were happy to have received Guided Care. In
summary, this 1-year pilot test supported the feasibility
and acceptability of recruiting, training, and deploying
a GCN to implement six of the eight major components
of the Guided Care model.
Funded by the John A. Hartford Foundation, the
Agency for Healthcare Research and Quality, the
National Institute on Aging, and the Jacob and Valeria
Langeloth Foundation, a 2-year cluster-randomized
controlled trial of Guided Care is now underway
(2006–2008) at eight nonacademic urban and suburban
primary care practices in the Baltimore/Washington,
DC, area. This study is evaluating the effects of Guided
Care on older patients with multimorbidity (physical
and mental health, quality and costs of care, and
satisfaction with care), caregivers (strain, costs, health,
and quality of care), primary care practices (physician
satisfaction, organizational dynamics), and GCNs (job
satisfaction). The pilot test and early phases of the
randomized controlled trial have provided four valu-
able lessons about implementing Guided Care.
1. GCN applicants should receive in writing a de-
tailed description of the role, responsibilities, and
scope of the GCN position. Some applicants may
otherwise assume erroneously that the job has the
narrower scope of case management or disease
management, or that it could be done primarily
2. Registered nurses with different backgrounds can
acquire the knowledge and skills required to
practice Guided Care. Experience with case
management, counseling, and geriatric nursing
is helpful, but it is not essential. The ability to
learn to use the EHR is essential.
3. The educational program that prepares registered
nurses to practice Guided Care should emphasize
topics that are specific to Guided Care, such as
using the EHR, developing Care Guides with
physicians and patients, conducting motivational
interviewing, educating and supporting care-
givers, and facilitating transitional care. Topics
related to traditional nursing should be reviewed
in less detail.
4. Support from primary care physicians is vital to
the success of Guided Care. Introductory letters
from physicians increase their patients’ willing-
ness to participate, and physicians’ cooperation
with the GCN is crucial to personalizing the
patients’ Care Guides.
These early experiences have also identified several
limitations in the capacity of Guided Care to improve
chronic care. Although the GCN facilitates access to
existing community resources, he or she cannot provide
funds to overcome obstacles that some patients experi-
ence, such as transportation, medication, equipment,
or home renovations. Furthermore, the nurse’s services
are limited to patients served by outpatient physician
groups and are limited to normal business hours.
Guided Care is the product of translating some of
the previous two decades’ most successful innovations
in chronic care into enhanced primary care for older
adults with multimorbidity. We designed Guided Care
to be attractive to American patients, caregivers,
providers, and insurers.
If the results of the ongoing multisite controlled trial
support the hypothesized beneficial effects of Guided
Care, we will begin efforts to diffuse Guided Care
throughout American health care. We will measure the
success of these efforts by the extent to which target
institutions adopt Guided Care, the extent of the
program’s reach into the target population, the con-
sistency of its implementation, its effectiveness in the
field, and the maintenance of its effects over time
(Berwick, 2003; Casalino et al., 2003; Glasgow, Vogt, &
Boles, 1999). Three specific issues will challenge the
diffusion of Guided Care.
The study will provide health insurers with detailed
information about expenditures for health care. We
designed Guided Care to reduce health care costs
by averting the need for some hospital care, thus off-
setting its operating costs. Either budget neutrality or
net savings would provide a rationale for insurance
programs, such as Medicare, to cover Guided Care
services, especially if they also improve quality of care,
quality of life, and satisfaction with care.
Adequacy of the Nursing Workforce
Thousands of registered nurses will need to learn
and practice the Guided Care model of nursing.
Although there is a shortage of hospital nurses in the
United States, the supply of nurses interested in
community-based positions may be sufficient. Guided
Care appeals to experienced nurses who seek to make
a difference in patients’ lives. Nurses working in related
fields (such as case management) report very high job
satisfaction (93%) that exceeds the national average for
nurses by 20%. Once hired, few nurses leave these
positions (annual turnover rate ¼ 3.0% vs 14.5% in
hospitals). The U.S. nursing profession’s Nursing
Agenda for the Future confirmed that promoting
‘‘integrated practice models across practice settings’’
is one of its ‘‘primary strategies’’ for attracting and
retaining qualified candidates for careers in nursing
(American Nurses Association, 2002, p. 11).
Adopting the Guided Care model does not require
deep organizational or structural change in the existing
health care delivery system, nor does it require
chronically ill older people to change primary care
physicians or limit their choice of other providers. It is
important to note that Guided Care is well suited not
only to large sophisticated health care organizations,
but also to the small-to-medium-sized groups in which
a majority of the nation’s primary physicians practice.
To facilitate the anticipated diffusion of Guided
Care throughout American health care, a stakeholder
advisory committee is helping to guide the ongoing
controlled trial. Representatives of the health insurance
industry, provider organizations, nursing education,
health care regulators, consumers, and policy makers
are advising the investigators to ensure that Guided
Care will be adoptable and positioned for widespread
diffusion upon completion of the study.
For the past two decades, many investigators and
innovators have discovered ways to improve the quality
and outcomes of several processes of health care for
several subgroups of chronically ill older people.
Guided Care translates and integrates the lessons
from many such experiments, spanning all of the major
components of the Chronic Care Model, in an effort to
transform America’s system of health care for vulner-
able older people with multiple chronic conditions.
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Received September 29, 2006
Accepted January 22, 2007
Decision Editor: Nancy Morrow-Howell, PhD