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Johns Hopkins' Guided Care

Guided Care is a model of comprehensive primary care in which a registered nurse, co-located in a primary care practice, partners with 3-4 physicians to provide coordinated, patient-centered, cost-effective care to 50-60 patients with multiple chronic conditions. Following a comprehensive in-home assessment and care planning process, the Guided Care nurse promotes patient self-management, monitors conditions monthly, coordinates efforts of all health care providers, smoothes transitions between sites of care, educates and supports family caregivers, and facilitates access to community resources. [Boyd CM et al. Gerontologist 2007]

Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002. In creating the Guided Care model, the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management, disease management, self-management, transitional care, geriatric evaluation, and caregiver support models into primary care. Guided Care integrates these successful innovations into primary care to make evidence-based, state-of-the-art chronic care available from professionals the patient trusts.

A 3-year multi-site, cluster-randomized controlled trial showed that, compared to usual care, Guided Care:

• Improves the quality of patients' chronic care [Boyd CM et al. J Gen Intern Med 2010]
• Improves physicians satisfaction with chronic care [Marsteller JA et al. Ann Fam Med 2010]
• Improves nurses' job satisfaction [Boult C et al. J Gerontol Med Sci 2008]
• May reduce the use and cost of expensive services, especially in well-managed systems [Boult C et al. Arch Intern Med 2011]

Guided Care is a well-defined model of primary care that primary care practices can fully implement in 6-9 months. Implementation involves hiring a registered nurse who has completed a course in Guided Care Nursing and integrating the nurse into the practice. Several forms of technical assistance are available for free to practices in the United States that plan to implement Guided Care or the principles of Guided Care as they develop into patient-centered medical homes or accountable care organizations. The resources include:

• Guided Care Implementation Manual. The book," Guided Care: A New Nurse-Physician Partnership in Chronic Care," contains information on preparing the practice for Guided Care, tools for hiring Guided Care nurses, a checklist for integrating nurses into practice, tools for managing Guided Care nurses, and other helpful resources. It is available in hard copy and electronic format. To request a free book, send an email to Tracy Novak at tnovak@jhsph.edu that summarizes your transformation plans.

• Patient education book about Guided Care. The book, "Transformation: A Family's Guide to Chronic Care, Guided Care, and Hope" by Tom Grundner, Ed.D., describes to chronically ill patients and their families what Guided Care is and how it can help them. It is available in hard copy and electronic formats, and an audio version is coming soon. To request a free book, send an email to Tracy Novak at tnovak@jhsph.edu that summarizes your transformation plans.

• An interactive, online course for registered nurses titled "Guided Care Nursing." The 6-week, 40-hour course features core and supplemental modules, live webinars and simulations, and support from expert faculty. After passing an online examination, the nurse receives a "Certificate in Guided Care Nursing" from the American Nurses Credentialing Center of the American Nurses Association. The course is offered by the Institute for Johns Hopkins Nursing. Scholarships are available – please visit www.ijhn.jhmi.edu for more information.

• An asynchronous, online course for leaders of practices titled "Practice Leaders in Medical Homes." The 9-module, 9-hour course will provide physicians, practice administrators, and other practice leaders with an awareness of competencies that facilitate effective physician practice within medical homes. Tuition is $15 per module. Physicians will receive a certificate and one CME credit for each one-hour module.  Other learners may qualify for continuing education credit from the American College of Medical Practice Executives (ACMPE). The course is offered by the Center for Teaching and Learning with Technology at the Johns Hopkins Bloomberg School of Public Health.

For more information, please visit www.GuidedCare.org for details about Guided Care and visit www.GuidedCare.org/adoption.asp for details about the free technical assistance. Funding for this technical assistance is provided by The John A. Hartford Foundation.