Guided Care Nurses help chronically ill patients

Nurse-physician collaboration is key to success

Older patients who are at high risk for health care utilization are staying healthier and out of the hospital thanks to a new primary care enhancement program called "Guided Care."

The Guided Care model, developed by a team of clinical researchers at Johns Hopkins University, is an interdisciplinary model of health care in which patients are supported by a nurse-physician primary care team that provides coordinated, patient-centered care to at-risk patients for the rest of their lives.

In a three-year, randomized, controlled trial involving 49 physicians and 904 older patients, researchers at the Johns Hopkins Bloomberg School of Public Health found patients who were treated using the Guided Care model cost health insurers 11% less than patients who received the usual care, according to Chad Boult, MD, MPH, MBA, principal investigator for the study and creator of the Guided Care model.

The Guided Care patients in the study, on average, experienced 24% fewer hospital days, 37% fewer skilled nursing facility days, 15% fewer emergency department visits, and 29% fewer home health care episodes.

"The key to success in the Guided Care model is to create a close relationship with the patient. The interventions of the model rely on evidenced-based guidelines for chronic conditions tailored to each patient. The nurse, the physician, and the patient can work within the model and produce good outcomes," says Cecelia M. Daub, RN, BSN, CCM, MA, Guided Care nurse at Kensington Medical Center of Kaiser Permanente's mid-Atlantic states region.

Daub participated in the randomized, controlled trial of Guided Care at Johns Hopkins and now works with four doctors in a primary care practice to managing about 60 patients.

She visits the patients in their homes - involving family members and caregivers if possible - sees them when they come for their primary care visits and goes over what the doctor told them, accompanies them to specialist appointments whenever possible, visits them in the hospital, and even meets them in the emergency department.

"We take a holistic approach to care and work with the patients in their home environment, surrounded by their loved ones," she says.

The Guided Care model uses predictive modeling software to identify patients older than 65 with chronic conditions and who are at high risk for health care utilization. Patients typically have hypertension, diabetes, congestive heart failure, chronic obstructive pulmonary disorder or coronary artery disease, or a combination of several conditions.

When patients are identified for the program, the nurse visits them in their home and conducts a comprehensive geriatric assessment and home safety evaluation.

"By seeing what they have to manage in the home environment, we get tremendous insight into what is going on. If there is a caregiver, a spouse or a child involved with the patient's care, we invite them to the initial session," she says.

The initial evaluation usually takes between an hour and a half and three hours.

"We customize the evaluation to the patient and the caregiver and the complexity of the patient's medical condition. When I conduct an evaluation, I leave an entire morning or afternoon free so the patient and caregiver will have a chance to get answers to all their questions. It sets up a very nice platform for a close relationship," she says.

When Daub completes the in-home assessment, she develops a preliminary care guide using evidence-based guidelines, then meets with the primary care physician to collaborate on a care guide.

"We see a lot of things in the home and bring the information back to the physicians. They are very appreciative. The physician may have been treating the patient for many years, but when we go into the home, we may find a situation that he or she wasn't aware of. By working together, we can develop a plan to address the patient's issues," she says.

Working with the physician, the nurse develops an action plan and shares it with the patient. The plan includes a medication list the patient can follow, as well as information on physical activity, diet, recommended procedures, and follow-up with specialists.

Daub encourages the patients to keep their action plan in a convenient location and bring it with them to specialists appointments - or if they go to the emergency department.

"The action plan becomes a point of communication between the different health care providers the patient sees and helps with continuity of care," she says.

By meeting with patients in their homes, the Guided Care nurses find out information they'd never discover during a telephone conversation, Daub points out.

"Medication reconciliation is of tremendous importance with the geriatric population because many patients are on multiple medications and get them mixed up. When we conduct in-home medication reviews, we may see pill bottles that are expired and other combinations of problems that could affect the patient's conditions. When I'm in the home, I can see what's going on and get to the bottom of their problems," she says.

Sometimes Daub knows that a physician has told the patient to use a walker or a cane at home and observes that he or she isn't doing it.

"This becomes an opportunity for a coaching session. Depending on the circumstances, I might discuss it with the patient at the time or follow up later," she says.

She may recommend a fall prevention class or educate the patient on the importance of safety in preventing falls.

"Because I'm in the home and have a good relationship with the patients, I can focus in on what they need to do to stay safe and healthy. Doctors don't have the time to coax their patients into following their advice," she says.

She works with the patients to identify red flags that indicate they should call Daub or their doctor.

For instance, she educates diabetics about safe blood sugar levels and what to do when blood sugar is higher or lower. She encourages them to check their feet regularly and call her if there's an open wound. She tells patients who have coronary artery disease, to call her if they have an increase in chest discomfort or palpitations.

"I educate them on monitoring activities they can do for themselves and give them guidelines for when to call me. I get more information and make a recommendation," she says.

The physicians decide on the frequency of monitoring that is included in the care guide. For instance, if the patient is on Coumadin, the physician indicates how often they need blood tests.

"Our system of technology allows me to put in reminders for myself. I can see the specialty visit notes and know what that physician has in the patient's plan, she says.

Daub reminds the patients to get regular screenings and procedures, such as mammograms or flu shots, and educates them on safety issues.

"I make suggestions such as installing grab bars in the home. If they don't accept the idea right away, I remind them later on. I check the smoke alarms and make sure they get new batteries if needed," she says.

She has contact with each patient a minimum of once a month but sees some patients much more frequently if necessary.

"I follow the patient in the outpatient setting, through any inpatient admissions, and help with the transition in care," she says.

Since she's located in the same office as the primary care physicians, when patients give permission, Daub accompanies them to their doctor visits, and then brings the patients back to her office to go over what the doctor said and make sure they understand it.

If the doctor changes the medication or the treatment plan, Daub can print out an updated action plan for the patient to follow.

"The Kaiser center I work in has primary care physicians with a laboratory, X-ray, and mammography downstairs. There's a same-day surgery and cataract surgery center here, and many of the specialists are next door. This kind of access to care is particularly helpful in providing continuity and cohesiveness of care to the geriatric population or anyone with mobility issues. If one of my patients has an appointment with a neurologist, I can easily walk over and sit in on it," Daub says.

Recently, a woman Daub was following was picking up her medication refill at the pharmacy and asked to see Daub because she wasn't feeling well.

"I took one look at her and knew she was in trouble. She told me her chest felt heavy and she wasn't breathing normally so I was afraid she was on the verge of a cardiac event," she says.

She notified the primary care physician, who saw the patient immediately and sent her to the emergency department.

During her conversation with the patient, Daub asked her why she was at the pharmacy and found out the woman had been out of her beta blocker for three days.

"She felt comfortable telling me but didn't mention it to the primary care doctor or the emergency room physician. This was a crucial piece of the emergency room treatment, but nobody would have known it if I hadn't had a close relationship with the patient," Daub says.

Daub informed the emergency department physician of the missed medication and educated the woman about the importance of taking care of her medicine. She got the woman's daughter involved in assuring that her mother gets her medications refilled promptly.

Patients can call Daub on her office phone when they need to within regular business hours, and she encourages them to do so.

"My patients appreciate the fact that when they call, there is a personal connection. It's the consistency. They aren't calling in to a call center. They know that they can always get a message directly to me in my voicemail," she says.

She also asks patients for permission to share private health information with their caregivers, so there are no barriers to communication between the patient, the caregivers, and the nurse.

When she gets a call that patients are going to the emergency room, Daub meets them whenever possible.

"Patients often have trouble explaining their situation and their medical history. I can give their background information to the emergency room physicians and they love it. It really helps them treat the patients in an effective and efficient manner," she says.

Guided Care nurses follow patients for the rest of their lives.

When patients are hospitalized, Daub doesn't actively manage the care but brings information to the treatment team.

"I'm in a listening role for what will happen after discharge. I find out if the patients will be able to go back to the same living situation, if any home modification will be needed, if the caregiver will have more responsibility than in the past, and work with all parties to achieve the best outcome," she says.

Her close relationship with her patients often helps with end-of-life issues. She tells of one diabetic patient who had a recurring abdominal infection.

"He'd go to rehab and work hard and something would happen again. One day I visited him in the hospital and he said, 'Please call them off. I just want to go home.' The family wasn't around and he was able to say what he really wanted. He was putting on a good face for his family and doing whatever the doctor asked him to do," she says.

Daub talked to the man's doctor, who had a discussion with him, then set up hospice care in the home.

"He was surrounded by his whole family. His wife made his favorite meal. A few days later he went into a coma and died at home. It was a dignified and happy death," she says.

(More information about Guided Care is available at The three-year trial of Guided Care was funded by a public-private partnership of the Agency for Healthcare Research and Quality, the National Institute of Aging, the John A. Hartford Foundation, the Jack and Valeria Langeloth Foundation, Kaiser Permanente Mid-Atlantic States Region, Johns Hopkins HealthCare, and the Roger C. Lipitz Center for Integrated Health Care.)