Guided Care: Evidence of CostEffectiveness

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Guided CareEvidence 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

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Guided Care

• A patient-centered medical home for patients with
  several chronic conditions

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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.

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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
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Who is Eligible?
All Patients Age 65
25 High-Risk
75 Low-Risk
Review previous years claims data with PM
software
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Randomized Trial

• High-risk older patients (n904) 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

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Baseline Characteristics
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Effects on Physician Satisfaction
p0.008
p0.066
p0.006
p0.034
p0.047
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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
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.
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Very satisfied
Satisfied
Somewhat satisfied
Somewhat dissatisfied
Dissatisfied
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
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Very Satisfied
Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Dissatisfied
Very Dissatisfied
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
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Effects on Caregiver Strain
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Annual Costs of Guided Care
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Effects on Costs of Care(per caseload, 55
patients)
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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)

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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

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Technical Assistancewww.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

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Grant Support

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