August 17, 2009

Guided care reduces cost for elders with chronic conditions

The nation’s sickest and most expensive patients need fewer health care resources and cost insurers less when they are closely supported by a nurse-physician primary care team that tracks their health and offers regular support, according to a study by researchers at the Johns Hopkins Bloomberg School of Public Health.

The research, published this month in the American Journal of Managed Care, found that in the first eight months of a randomized controlled trial, patients in a primary care enhancement program called Guided Care spent less time in hospitals and skilled nursing facilities and had fewer emergency room visits and home health episodes.

“Guided Care patients cost health insurers 11 percent less than patients in the control group,” said Chad Boult, the principal investigator of the study and creator of the Guided Care model. “If you apply that rate of savings to the 11 million eligible Medicare beneficiaries, programs like Guided Care could save Medicare more than $15 billion every year,” said Boult, the Eugene and Mildred Lipitz Professor in Health Care Policy at the Bloomberg School and director of the Lipitz Center for Integrated Health Care.

Compared to patients who received usual care, Guided Care patients experienced, on average, 24 percent fewer hospital days, 37 percent fewer skilled nursing facility days, 15 percent fewer emergency department visits and 29 percent fewer home health care episodes, according to the study.

Lead author Bruce Leff, associate professor in the Bloomberg School’s Department of Health Policy and Management and in the School of Medicine’s Department of Medicine, said, “While Guided Care patients received more personal attention from their care team and had more physician office visits, the avoided expenses related to care in hospitals, skilled nursing facilities and emergency departments more than offset all the costs of providing Guided Care. The program realized annual net savings of $75,000 per nurse, two-thirds of which resulted from reductions in hospitalization,” he said.

Other studies have shown that Guided Care improves the quality of patients’    care, reduces family caregiver strain and improves physicians’ satisfaction with chronic care.

Guided Care is a model of proactive, comprehensive health care provided by physician-nurse teams for people with several chronic health conditions and is designed to improve patients’ quality of life and care while improving the efficiency of treating the sickest and most complex patients.

The care teams include a registered nurse, two to five physicians, and staff members who work together to perform a comprehensive patient assessment at home, create an evidence-based care guide and action plan, monitor and coach the patient monthly, coordinate the efforts of all the patient’s health care providers, smooth the patient’s transition between sites of care, promote patient self-management, educate and support family caregivers, and facilitate access to appropriate community resources.

A multisite randomized controlled trial of Guided Care involving 49 physicians, 904 older patients and 319 family members recently concluded in eight locations in the Baltimore-Washington, D.C., area. The three-year study was funded by a public-private partnership of the Agency for Healthcare Research and Quality, National Institute on Aging, John A. Hartford Foundation, Jacob and Valeria Langeloth Foundation, Kaiser Permanente Mid-Atlantic States, Johns Hopkins HealthCare and the Roger C. Lipitz Center for Integrated Health Care.

Additional authors of the study are Lisa Reider, Kevin D. Frick, Daniel D. Scharfstein, Cynthia M. Boyd and Katherine Frey, all of Johns Hopkins; and Lya Karm, of Kaiser Permanente Mid-Atlantic States.

The Guided Care model was developed by a team of clinical researchers at Johns Hopkins University beginning in 2001. The team is supported by a Stakeholder Advisory Committee comprising national leaders in medicine, nursing, health policy, patient advocacy and health insurance. For more information, go to