Search the Health Library
Get the facts on diseases, conditions, tests and procedures.
I Want To...
Find a Doctor
Find a doctor at The Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center or Johns Hopkins Community Physicians.
I Want To...
Find Research Faculty
Enter the last name, specialty or keyword for your search below.
Guided Care Nursing
Team Approach for Chronic Care of the Elderly
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.
Our self-paced, 40 hour online course prepares registered nurses to become Guided Care Nurses. It features core and supplemental modules, live webinars and simulations, and support from expert faculty from the Institute for Johns Hopkins Nursing. After passing an online exam, the nurse receives a Certificate in Guided Care Nursing from the American Nurses Credentialing Center.
In Guided Care, a specially-educated registered nurse works in partnership with primary care physicians and caregivers to support a practice’s sickest patients by:
- Assessing the patient and their primary caregiver at home
- Creating an evidence-based care plan for providers and an action plan for patients and caregivers
- Promoting patient self-management
- Monitoring patients’ conditions monthly
- Coordinating the efforts of all care providers (hospitals, specialists, rehab facilities, home care, hospice, and social service agencies)
- Smoothing transitions between sites of care, (e.g., transitions into and out of hospitals)
- Educating and supporting family caregivers
- Facilitating access to community resources