Guided Care:
Evidence of Cost-Effectiveness
Chad Boult, MD, MPH, MBA
Professor of Public Health, Medicine and Nursing
Johns Hopkins University
PCPCC Annual Summit
Washington DC
October 22, 2009
“Guided Care”
A patient-centered medical home for
patients with several chronic conditions
What is Guided Care Look Like?
A practice-based RN collaborates with 2-5
physicians in caring for 50-60 of their most
complex patients.
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
Boyd et al. Gerontologist Nov 2007
Who is Eligible?
25%
High-Risk
All Review previous
Patients year’s claims data
with PM software
Age 65+ 75%
Low-Risk
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
Baseline Characteristics
Guided Care Usual Care
Age 77.2 78.1
Race (% white) 51.1 48.9
Sex (% female) 54.2 55.4
Education (12+) 46.4 43.4
Living alone 32.0 30.6
Conditions 4.3 4.3
HCC score 2.1 2.0*
ADL difficulty 30.9 29.3
Cognition (SPMS) 0.9 1.0
Effects on Physician Satisfaction
0.5 p=0.008
0.4 p=0.066 p=0.006
p=0.034
0.3
0.5
0.2 0.39 0.39
p=0.047 0.29
0.1
Guided Care
0.11
Physicians
0 (n=18)
-0.11 Usual Care
-0.18 Physicians
-0.1 (n=20)
-0.34
-0.2 -0.42 -0.4
-0.3
-0.4
-0.5
Communicating with Communicating with Educating Motivating Knowing Patients'
Patients Caregivers Caregivers Patients Meds
Effects on Quality of Care
PACIC scales
2.1
AGGREGATE
1.3
Activation
1.3
Problem Solving
1.5
Decision Support
1.8
Coordination
1.5
Goal Setting
0 1 2 3 4
aOR
Quality rated in the highest category on PACIC
Adjusted for participants’ baseline age, race, sex, educational level, financial status, habitation status, HCC score, functional
ability (i.e., SF-36 physical component summary and mental component summary scores), subscale-specific baseline
PACIC score, satisfaction with health care, and practice site.
GCNs' Satisfaction with Clinical
6
Activities
Very satisfied
Satisfied 5
Somewhat satisfied 4
Somewhat dissatisfied 3
Dissatisfied 2
Very dissatisfied 1
1 2 3 4 5 6 7
Satisfaction Items
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
GCNs' Satisfaction with Role
Very Satisfied 6
Satisfied 5
Somewhat Satisfied 4
Somewhat Dissatisfied 3
Dissatisfied 2
Very Dissatisfied 1
1 2 3 4 5 6
Satisfaction Items
Satisfaction Items
1= Autonomy/flexibility; overall satisfaction
2= Client interaction
3= Diversity of tasks; amount of challenge
4= Relationship with PCPs
5= Interaction with coworkers; manageability of workload
6= Relationship with other physicians
Effects on Caregiver Strain
Annual Costs of Guided Care
Guided Care Nurse
Salary $71,500
Benefits (@ 30%) 21,450
Travel (to pts’ homes, hospitals) 588
Communication services
Internet, cell phone 1,800
Equipment (amortized over 3 years)
Computer 500
Cell phone 67
TOTAL $95,905
Effects on Costs of Care
(per caseload, 55 patients)
GC – UC Average Cost
Difference Expenditure Difference
Hospital days -76.1 $1,519/day -115.6
SNF days -99.1 $305/day -30.2
Home health
-20.1 $1331/episode -26.8
episodes
Physician visits 40.0 $41/visit 1.7
Gross savings ----- ----- -170.9
Cost of GCN 95.9
NET SAVINGS ----- ----- -75.0
How Well Does Guided Care Work?
A pilot test and a multi-site RCT show:
– Improved quality of care
– Improved physician satisfaction with care
– Reduced strain for family caregivers
– High job satisfaction for nurses
– Cost savings for insurers
Sylvia M et al. Dis Manag Feb 2008
Boyd C et al. J Gen Intern Med Feb 2008
Boult C et al. J Gerontol Med Sci Mar 2008
Wolff et al. J Geront Med Sci June 2009
Leff B et al. Am J Manag Care August 2009
Boyd C et al. J Gen Intern Med 2010 (in press)
Adopting Guided Care
• Care management fees
• Commitment by practice staff
• A Guided Care nurse
• Office, computer, cell phone
• Integration of the nurse into the practice
• Technical assistance
Technical Assistance
www.MedHomeInfo.org
• Guided Care implementation manual
• On-line course for Guided Care nurses
• On-line course for physicians and practice
leaders
• Guidance in selecting HIT
• Online practice self-assessment (“MHIQ”)
• Regional weekend “Learning Collaboratives”
• Ongoing electronic “Learning Communities”
Grant Support
John A. Hartford Foundation
Agency for Healthcare Research and Quality
National Institute on Aging
Jacob and Valeria Langeloth Foundation