Guided care: a new frontier for adults with chronic conditions.
OBJECTIVE
This article describes "Guided Care," a promising new model of case management that includes disease management, self-management, transitional care, and caregiver support for multimorbid patients and their families.


METHODS
Guided Care nurses, based at primary care practices, extend services to the home and all the other settings where their patients receive care.


CONCLUSIONS
Guided Care nurses take responsibility for 50-60 multimorbid patients. For each patient, the nurse performs a home assessment and creates an evidence-based plan of care. In partnership with the primary physician, the Guided Care nurse then monitors and coaches the patient monthly, coordinates the patient's transitions between providers and sites of care, educates and supports family caregivers, and facilitates access to community resources.


CONCLUSIONS
As a next stage in the evolution of case management, Guided Care may be supported by Medicare and, therefore, adopted widely throughout the American healthcare.
Aliotta
Sherry L
SL
S.A. Squared of Tennessee, Inc., Evansville, IN 47701, USA. sherry@sa2cm.com
Grieve
Kathleen
K
Giddens
Jean F
JF
Dunbar
Linda
L
Groves
Carol
C
Frey
Katherine
K
Boult
Chad
C
D000368:Aged; D015142:Baltimore; D019090:Case Management / Q000458:organization & administration*; D002908:Chronic Disease / Q000451:nursing / Q000517:prevention & control* / Q000523:psychology; D015897:Comorbidity; D003266:Continuity of Patient Care / Q000458:organization & administration; D019468:Disease Management; D019317:Evidence-Based Medicine; D005240:Feasibility Studies; D006792:House Calls; D006801:Humans; D016294:Models, Nursing; D024802:Nurse's Role; D009730:Nursing Assessment; D015403:Nursing Evaluation Research; D009736:Nursing Process / Q000458:organization & administration; D010347:Patient Care Planning / Q000458:organization & administration*; D010353:Patient Education as Topic / Q000458:organization & administration; D010865:Pilot Projects; D011320:Primary Health Care / Q000458:organization & administration*; D015397:Program Evaluation; D012648:Self Care / Q000379:methods; D012944:Social Support