title: Guided care for multimorbid older adults.
abstract: OBJECTIVE
  The purpose of this study was to test the feasibility of a new model of health care designed to improve the quality of life and the efficiency of resource use for older adults with multimorbidity.
  
  
  METHODS
  Guided Care enhances primary care by infusing the operative principles of seven chronic care innovations: disease management, self-management, case management, lifestyle modification, transitional care, caregiver education and support, and geriatric evaluation and management. To practice Guided Care, a registered nurse completes an educational program and uses a customized electronic health record in working with two to five primary care physicians to meet the health care needs of 50 to 60 older patients with multimorbidity. For each patient, the nurse performs a standardized comprehensive home assessment and then collaborates with the physician, the patient, and the caregiver to create two comprehensive, evidence-based management plans: a Care Guide for health care professionals, and an Action Plan for the patient and caregiver. Based in the primary care office, the nurse then regularly monitors the patient's chronic conditions, coaches the patient in self-management, coordinates the efforts of all involved health care professionals, smoothes the patient's transitions between sites of care, provides education and support for family caregivers, and facilitates access to community resources.
  
  
  RESULTS
  A 1-year pilot test in a community-based primary care practice suggested that Guided Care is feasible and acceptable to physicians, patients, and caregivers.
  
  
  CONCLUSIONS
  If successful in a controlled trial, Guided Care could improve the quality of life and efficiency of health care for older adults with multimorbidity.
authors.affiliation: Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA. cyboyd@jhmi.edu
authors.forename: Cynthia M
authors.initials: CM
authors.lastname: Boyd
authors.forename: Chad
authors.initials: C
authors.lastname: Boult
authors.forename: Efrat
authors.initials: E
authors.lastname: Shadmi
authors.forename: Bruce
authors.initials: B
authors.lastname: Leff
authors.forename: Rosemarie
authors.initials: R
authors.lastname: Brager
authors.forename: Linda
authors.initials: L
authors.lastname: Dunbar
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Wolff
authors.forename: Stephen
authors.initials: S
authors.lastname: Wegener
mesh_terms: D000368:Aged; D002908:Chronic Disease / Q000451:nursing*; D015897:Comorbidity; D003695:Delivery of Health Care / Q000458:organization & administration*; D017598:Efficiency, Organizational; D006801:Humans; D007318:Inservice Training; D016347:Medical Records Systems, Computerized; D008962:Models, Theoretical; D011320:Primary Health Care / Q000458:organization & administration; D011788:Quality of Life