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Guided Care Nursing

nurse with patient

THE CHALLENGE

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 SOLUTION

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

OUTCOMES

  • 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

BECOME A GUIDED CARE NURSE

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