Caring for older adults with chronic conditions and complex health needs is becoming increasingly challenging. Guided Care addresses the lack of an efficient, cost-effective way to respond to the needs of patients with either chronic illnesses or co-morbidities. Research shows that Guided Care reduces the use of expensive health services for chronically ill older adults.
The Guided Care® model consists of a Guided Care nurse, based in a primary care office, working with 2 to 5 physicians and other care team members to provide coordinated, patient-centered, cost-effective health care to 50 to 60 of their chronically ill patients. The nurse conducts in-home assessments, promotes patient self-management, facilitates care planning, monitors conditions, coordinates care efforts, smooths transitions, educates family caregivers, and more.
Unlike most care/case management interventions, Guided Care focuses on the role of the Guided Care Nurse, who:
- Is based in the primary care physician’s office
- Works with the patient long-term, usually for life
- Provides intensive transitional care
- Uses motivational interviewing to help patients manage their conditions
- Provides continuing education, resources, and support for family caregivers
- Improves the quality of patient care
- Improves family caregivers’ perception of quality of care
- Produces high job satisfaction among Guided Care nurses
- Improves physicians’ satisfaction with chronic care
- May reduce the use of expensive services