Skip Navigation Archive: U.S. Department of Health and Human Services U.S. Department of Health and Human Services
Archive: Agency for Healthcare Research Quality
Archival print banner

This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: Let us know the nature of the problem, the Web address of what you want, and your contact information.

Please go to for current information.

Linking Clinical Practice and Community Resources: The Guided Care Model

Slide presentation from the AHRQ 2009 conference.

On September 14, 2009, Chad Boult made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (626 KB).

Slide 1

Slide 1. Linking Clinical Practice and Community Resources: The Guided Care Model

Linking Clinical Practice and
Community Resources:

The Guided Care Model

Chad Boult, MD, MPH, MBA
Professor of Public Health, Medicine and Nursing
Johns Hopkins University

AHRQ 2009 Annual Conference
September 14, 2009

Slide 2

Slide 2. Ms. Marian Chen

Ms. Marian Chen

  • 79 year old widow
  • Retired teacher, lives alone
  • Income: SS, pension and Medicare
  • Daughter, lives 10 miles away with three teenagers
  • Five chronic conditions
  • Three physicians
  • Eight medications


Slide 3

Slide 3. In 2009, Mrs. Chen has had . . .

In 2009, Mrs. Chen has had...


Slide 4

Slide 4. Mrs. Chen and Her Daughter

  • Mrs. Chen
    • Confused by care, meds
    • Poor quality of life
    • High out-of-pocket costs
  • Daughter
    • Stressed out
    • Reduced work to half-time
    • Considering nursing homes

Medicare paid $42,400 to providers for her care
(not including medications)


Slide 5

Slide 5. Chronic care is:

Chronic care is:

  • Fragmented
  • Discontinuous
  • Difficult to access
  • Inefficient
  • Unsafe
  • Expensive


Slide 6

Slide 6. The ¼ of Beneficiaries Who Have 4+ Chronic Conditions Account for 80% of Medicare Spending

Source: Medicare 5% Sample, 2001
The 1/4 of Beneficiaries Who Have 4+ Chronic Conditions Account for 80% of Medicare Spending


Slide 7

Slide 7. Goals


  • Create a model that improves quality of care and reduces costs
  • Make the model diffusable throughout the United States


Slide 8

Slide 8. The Guided Care Model

The Guided Care Model

  • Specially trained RNs based in primary physicians' offices
  • GCNs collaborate with physicians in caring for 50-60 high-risk older patients with chronic conditions and complex health care needs


Slide 9

Slide 9. Nurse/Physician Team

Nurse/physician team

  • Assesses needs and preferences
  • Creates an evidence-based "care guide" and a patient-friendly "action plan"
  • Monitors the patient proactively
  • Supports chronic disease self-management
  • Smoothes transitions between care sites
  • Communicates with providers in EDs, hospitals, specialty clinics, rehab facilities, home care agencies, hospice programs, and social service agencies in the community
  • Educates and supports caregivers
  • Facilitates access to community services


Slide 10

Slide 10. Linking with Community Resources

Linking with Community Resources

  • Data base of local community resources
  • Facilitate access to appropriate services
    • Empowerment
    • Paternalism
  • Meals on Wheels, senior centers, AAA, transportation programs, adult day care, CDSMP, social workers, pharmacists
  • GCN support groups? community support groups


Slide 11

Slide 11. Image about improved outcomes

[Image about improved outcomes]


Slide 12

Slide 12. Who is Eligible?

Who is Eligible?

Age 65+

Review previous year's claims data with HCC software


Slide 13

Slide 13. Randomized Trial

Randomized Trial

  • High-risk older patients (n=904) of 49 community-based primary care physicians practicing in 14 teams
  • Physician/patient teams randomly assigned to receive Guided Care or "usual" care
  • Outcomes measured at 8, 20 and 32 months


Slide 14

Slide 14. Baseline Characteristics

Baseline Characteristics


Slide 15

Slide 15. Effects on Physician Satisfaction

Effects on Physician Satisfaction


Slide 16

Slide 16. GCN's Satisfaction with Clinical Activities (Graph)

Very Satisfied
Very Dissatisfied
Satisfaction Items
1= Familiarity with patients
2= Stability of patient relationships
3= Comm. w/ patients; Availability of clinical info; continuity of care for patients
4= Efficiency of office visits; access to evidence based guidelines
5= Monitoring patients; communicating w/ caregivers; efficiency of primary care team
6= Coordinating care; referring to community resources; educating caregivers
7= Motivating patients for self management
Somewhat Satisfied
Somewhat Dissatisfied


Slide 17

Slide 17. Effects on Quality of Care

Effects on Quality of Care

* Adjusted for baseline socio-demographics, health, function, PACIC scores, site


Slide 18

Slide 18. Effects on Caregiver Strain

Effects on Caregiver Strain


Slide 19

Slide 19. Annual Costs of Guided Care

Annual Costs of Guided Care


Slide 20

Slide 20. Effects on Costs of Care (per caseload, 55 patients)

Effects on Costs of Care
(per caseload, 55 patients)


Slide 21

Slide 21. Early Results

Early Results

  • Guided Care improves the quality of chronic care.
  • Guided Care reduces net expenditures for health care.
  • Guided Care is easy to implement and popular with physicians, nurses, patients and caregivers.


Slide 22

Slide 22. Future Directions

Future Directions

  • National pilot test involving Guided Care medical homes
  • Technical assistance
    • Book
    • Online course and certificate for nurses
    • Online course for physicians
    • Guidance in selecting HIT
    • Learning collaboratives and communities
    • Consultation


Slide 23

Slide 23. Grant Support

Grant Support

  • Agency for Healthcare Research and Quality
  • National Institute on Aging
  • John A. Hartford Foundation
  • Jacob and Valeria Langeloth Foundation


Slide 24

Slide 24. Publications


  • Boyd C et al. Gerontologist Nov 2007
  • Sylvia M et al. Dis Manag Feb 2008
  • Boyd C et al. J Gen Intern Med Feb 2008
  • Boult C et al. J Gerontology Mar 2008
  • Wolff et al. J Gerontology June 2009
  • Leff B et al. Am J Managed Care August 2009
  • "Guided Care: a New Nurse-Physician Partnership for Chronic Care." Springer Publishing Co. 2009
  • (
Current as of December 2009
Internet Citation: Linking Clinical Practice and Community Resources: The Guided Care Model. December 2009. Agency for Healthcare Research and Quality, Rockville, MD.


The information on this page is archived and provided for reference purposes only.


AHRQ Advancing Excellence in Health Care