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Beyond Case Management

Research shows the more education and monitoring a patient has for his disease, the better the outcomes. Case management is one way to fill that need.

However, a new paradigm gives case management a big boost. Described by a nurse in the program as "case management on steroids," and by a patient/caregiver as "a program we have absolutely benefitted from," the Guided Care (GC) model pairs nurses, who are based in a primary care practice, in regular interaction with geriatric patients with comorbidities. Uniquely, the program includes the nurse working with caregivers as well.

What is Guided Care?

GC was created by a multidisciplinary team at the Lipitz Center for Integrated Health Care at Johns Hopkins Bloomberg School of Public Health, Baltimore, to improve the quality of life for older adults with multiple health issues requiring complex care, and to offer support in various forms to the caregivers of these patients.

Originally pilot-tested in a 1-year program in 2003, this led to a cluster-randomized controlled trial (cRCT) in 2006 at eight sites in the Baltimore/Washington, DC area. The program was open to selected patients of fee-for-service Medicare, U.S. Family Health Plan for retired military and Kaiser Permanente Mid-Atlantic.

The cRCT wrapped up last month, but the program will continue at two health systems, Johns Hopkins HealthCare and Kaiser Permanente Mid Atlantic.

GC is "an enhancement of case management," according to Kathleen Trainor Grieve, MHA, BSN, RN, CCM, of Johns Hopkins HealthCare, one of seven GC nurses. "The fact each of us is embedded in a primary care physician's practice, that we are seen as a partner of the physician, rather than a representative of the payer; that we actively monitor patients over a long period of time, as well as provide support and education to caregivers - these things make Guided Care unique." Grieve pointed out patients remain in the program for as long as they wish to participate.

Even though GC is brand new, a GC nursing certificate is already available from the American Nurses Credentialing Center. Grieve is one of the instructors in the GC course. (Interested in learning more? Go to, click on Regions, then MD, DC, VA and look for "How to Become a Guided Care Nurse.")

The Program Skinny

Key to the program is an electronic health record and regular interaction of nurses with patients. The GC nurse, with a caseload of 50-60 patients, works with the primary care physician to facilitate eight clinical processes:

• "assessing a patient at home;

• creating an evidence-based care plan;

• promoting patient self-management;

• proactively monitoring the patient's conditions;

• coaching the patient to practice healthy behaviors;

• coordinating patient's transitions between sites and providers of care;

• facilitating access to community resources; and

• educating and supporting caregivers" (Wolff, J.L. 2009, Journal of Gerontology).

Initial assessments, using motivational interviewing, are done in the patient's home, as octogenarians Lorraine and John Puls experienced when their doctor recommended they get involved in GC early in the study.

"Kathleen came to our house," remembered Lorraine of Perry Hall, MD. "She went through the house and made recommendations, such as removing scatter rugs, adding a second railing on the basement stairs."

Uniquely, the Puls are both enrolled as patients, while Lorraine, 81, acts as caregiver for John, 84, who has mild dementia.

Five years into the program, Lorraine is still excited about GC. "Initially I thought the program sounded wonderful, but sometimes programs are strong for awhile and then die out," she said. "Not so with this! Kathleen calls every month, reviews any health issues that have cropped up, advises on diet and exercise and keeps track of changes in medications."

Grieve and other GC nurses can attend doctor visits with the patient, as well as keep specialists and the primary care physician apprised of changes in health status. They also offer individual and group assistance to caregivers on many different issues.

Beyond Case Management

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