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Guided Care:Evidence of Cost-Effectiveness
Chad Boult, MD, MPH, MBAProfessor of Public Health, Medicine and Nursing
Johns Hopkins University
PCPCC Annual SummitWashington 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 preferencesCreates an evidence-based “care guide”
and a patient-friendly “action plan”Monitors the patient proactivelySupports chronic disease self-managementSmoothes transitions between care sitesCommunicates with providers in EDs,
hospitals, specialty clinics, rehab facilities, home care agencies, hospice programs, and social service agencies in the community
Educates and supports caregiversFacilitates 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 year’s claims data with PM
software
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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
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Baseline CharacteristicsGuided 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
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Effects on Physician Satisfaction
0.11
0.39
0.5
0.390.29
-0.42
-0.11
-0.34-0.4
-0.18
-0.5
-0.4
-0.3
-0.2
-0.1
0
0.1
0.2
0.3
0.4
0.5
Communicating with Patients
Communicating with Caregivers
Educating Caregivers
Motivating Patients
Knowing Patients' Meds
Guided Care Physicians (n=18)
Usual Care Physicians (n=20)
p=0.047
p=0.066
p=0.008
p=0.006
p=0.034
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AGGREGATE
Activation
Decision Support
Problem Solving
Coordination
Goal Setting
0 1 2 3 4
aOR
Effects on Quality of Care2.1
1.3
1.3
1.5
1.5
1.8
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.
PACIC scales
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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
GCNs' Satisfaction with Clinical Activities
1
2
3
4
5
6
1 2 3 4 5 6 7
Satisfaction Items
Satisfied
Somewhat satisfied
Somewhat dissatisfied
Dissatisfied
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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
Very Satisfied
Very Dissatisfied
Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Dissatisfied
GCNs' Satisfaction with Role
1
2
3
4
5
6
1 2 3 4 5 6
Satisfaction Items
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Effects on Caregiver Strain
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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
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Effects on Costs of Care(per caseload, 55 patients)
GC – UC Difference
AverageExpenditure
CostDifference
Hospital days -76.1 $1,519/day -115.6
SNF days -99.1 $305/day -30.2
Home health episodes
-20.1 $1331/episode -26.8
Physician visits 40.0 $41/visit 1.7
Gross savings ----- ----- -170.9
Cost of GCN 95.9
NET SAVINGS ----- ----- -75.0
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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 2008Boyd C et al. J Gen Intern Med Feb 2008
Boult C et al. J Gerontol Med Sci Mar 2008Wolff et al. J Geront Med Sci June 2009
Leff B et al. Am J Manag Care August 2009Boyd 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 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”
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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