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Guided Care Nursing

nurse with patient


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




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