Linking Clinical Practice and Community Resources: The Guided Care Model Chad Boult, MD, MPH, MBA Professor of Public Health, Medicine and Nursing Johns Hopkins University AHRQ 2009 Annual Conference September 14, 2009

Ms. Marian Chen 79 year old widow Retired teacher, lives alone Income: SS, pension and Medicare Daughter, lives 10 miles away with three teenagers Five chronic conditions Three physicians Eight medications

In 2009, Mrs. Chen has had… 6 community referrals 2 home care agencies 5 months homecare 2 nursing homes 6 weeks sub- acute care 3 hospital admissions 19 outpatient visits 8 meds 22 scripts Mrs. Chen

Mrs. Chen Confused by care, meds Poor quality of life High out-of-pocket costs Medicare paid $42,400 to providers for her care (not including medications) Daughter Stressed out Reduced work to half-time Considering nursing homes

Chronic care is: Fragmented Discontinuous Difficult to access Inefficient Unsafe Expensive

Source: Medicare 5% Sample, 2001 The ¼ of Beneficiaries Who Have 4+ Chronic Conditions Account for 80% of Medicare Spending

Goals Create a model that improves quality of care and reduces costs Make the model diffusable throughout the United States

The Guided Care Model Specially trained RNs based in primary physicians’ offices GCNs collaborate with physicians in caring for high-risk older patients with chronic conditions and complex health care needs

Nurse/physician team Assesses needs and preferences Creates an evidence-based “care guide” and a patient-friendly “action plan” Monitors the patient proactively Supports chronic disease self-management Smoothes transitions between care sites Communicates with providers in EDs, hospitals, specialty clinics, rehab facilities, home care agencies, hospice programs, and social service agencies in the community Educates and supports caregivers Facilitates access to community services

Linking with Community Resources Data base of local community resources Facilitate access to appropriate services –Empowerment –Paternalism Meals on Wheels, senior centers, AAA, transportation programs, adult day care, CDSMP, social workers, pharmacists GCN support groups  community support groups

Informed, Activated Patient Chronic Disease Self-Management, Caregiver Support, Action Plan Productive Interactions Prepared, Proactive Practice Team Monitoring Coaching Improved Outcomes Delivery System Design Guided Care Nurse Decision Support Lexi-comp, Evidence-based guidelines Clinical Information Systems Electronic Health Record, Care Guide, Transitional Care, Coordination Self- Management Support Chronic Disease Self- Management Health System Community Resources and Policies Accessing Health Care Organization

Who is Eligible? All Patients Age % High-Risk 75% Low-Risk Review previous year’s claims data with HCC software

Randomized Trial High-risk older patients (n=904) of 49 community-based primary care physicians practicing in 14 teams Physician/patient teams randomly assigned to receive Guided Care or “usual” care Outcomes measured at 8, 20 and 32 months

Baseline Characteristics Guided CareUsual Care Age Race (% white) Sex (% female) Education (12+) Living alone Conditions4.3 HCC score * ADL difficulty Cognition (SPMS)

Effects on Physician Satisfaction Guided Care (n=18) Usual Care (n=20) P Communicating with patients Communicating with caregivers Educating caregivers Motivating patients Know all pt’s meds

Very Satisfied Very Dissatisfied Satisfaction Items 1= Familiarity with patients 2= Stability of patient relationships 3= Comm. w/ patients; Availability of clinical info; continuity of care for patients 4= Efficiency of office visits; access to evidence based guidelines 5= Monitoring patients; communicating w/ caregivers; efficiency of primary care team 6= Coordinating care; referring to community resources; educating caregivers 7= Motivating patients for self management Satisfied Somewhat Satisfied Somewhat Dissatisfied Dissatisfied

Effects on Quality of Care PACIC scales:GCUC aOR * 95% CI P Goal setting <0.001 Coordination Decision support Problem solving Patient activation Aggregate * Adjusted for baseline socio-demographics, health, function, PACIC scores, site

Effects on Caregiver Strain

Annual Costs of Guided Care Guided Care Nurse Salary$71,500 Benefits 30%)21,450 Travel (to pts’ homes, hospitals)588 Communication services Internet, cell phone1,800 Equipment (amortized over 3 years) Computer500 Cell phone67 TOTAL$95,905

Effects on Costs of Care (per caseload, 55 patients) GC – UC Difference Average Expenditure Cost Difference Hospital days-76.1$1,519/day SNF days-99.1$305/day-30.2 Home health episodes -20.1$1331/episode-26.8 Physician visits40.0$41/visit1.7 Gross savings Cost of GCN95.9 NET SAVINGS

Early Results Guided Care improves the quality of chronic care. Guided Care reduces net expenditures for health care. Guided Care is easy to implement and popular with physicians, nurses, patients and caregivers.

Future Directions National pilot test involving Guided Care medical homes Technical assistance –Book –Online course and certificate for nurses –Online course for physicians –Guidance in selecting HIT –Learning collaboratives and communities –Consultation

Grant Support Agency for Healthcare Research and Quality National Institute on Aging John A. Hartford Foundation Jacob and Valeria Langeloth Foundation

Publications Boyd C et al. Gerontologist Nov 2007 Sylvia M et al. Dis Manag Feb 2008 Boyd C et al. J Gen Intern Med Feb 2008 Boult C et al. J Gerontology Mar 2008 Wolff et al. J Gerontology June 2009 Leff B et al. Am J Managed Care August 2009 “Guided Care: a New Nurse-Physician Partnership for Chronic Care.” Springer Publishing Co (