OBJECTIVE: Improving health care of multimorbid older adults is a critical public health challenge. The objective of this study is to evaluate the effect of a pilot intervention to enhance the quality of primary care experiences for chronically ill older persons (Guided Care). DESIGN: Nonrandomized prospective clinical trial. PATIENTS/PARTICIPANTS: Older, chronically ill, community-dwelling patients (N=150) of 4 General Internists in 1 urban community practice setting who were members of a capitated health plan and identified as being at high risk of heavy use of health services in the coming year by claims-based predictive modeling. INTERVENTIONS: Guided Care, an enhancement to primary care that incorporates the operative principles of chronic care innovations, was delivered by a specially trained, practice-based registered nurse working closely with 2 primary care physicians. Each patient received a geriatric assessment, a comprehensive care plan, evidence-based primary care with proactive follow-up of chronic conditions, coordination of the efforts of health professionals across all health care settings, and facilitated access to community resources. MEASUREMENTS AND MAIN RESULTS: Quality of primary care experiences (physician-patient communication, interpersonal treatment, knowledge of patient, integration of care, and trust in physician) was assessed using the Primary Care Assessment Survey (PCAS) at baseline and 6 months later. At baseline, the patients assigned to receive Guided Care were similar to those assigned to receive usual care in their demographics and disability levels, but they had higher risk scores and were less likely to be married. Thirty-one of the 75 subjects assigned to the Guided Care group received the intervention. At 6 months, intention-to-treat analyses adjusting for age, gender, and risk score suggest that Guided Care may improve the quality of physician-patient communication. In per-protocol analyses, receipt of Guided Care was associated with more favorable change than usual care from baseline to follow-up in all 5 PCAS domains, but only physician-patient communication showed a statistically significant improvement. CONCLUSIONS: In this pilot study, Guided Care appeared to improve the quality of primary care experiences for high-risk, chronically ill older adults. A larger cluster-randomized controlled trial of Guided Care is underway.
Bibliographical noteFunding Information:
Acknowledgment: We appreciate the administrative assistance of Sharon Kuta and Adriane King and the thoughtful comments of Dr. Rachel Levine. We thank the patients who enrolled in GC, their caregivers, the GCN, and the physicians. We acknowledge the contributions of Katherine Frey, MPH; Lisa Reider, MHS; and Carlos O. Weiss, MD, MHS, to the model of GC including the development of the care guides and personal action plans. Funding for the development and pilot-testing of GC: Johns Hopkins HealthCare contributed the funding and administrative support for the GCN, the development of the EHR, and the analysis of claims data and supported Martha Sylvia’s time. Johns Hopkins Community Physicians contributed access to patients, the efforts of the PCPs, and office space and equipment at the community-based primary care practice. The Roger C. Lipitz Center for Integrated Health Care contributed seed funding, administrative support, and support for data analysis. Dr. Boyd was supported by the Johns Hopkins Bayview Scholars at the Center for Innovative Medicine at the Johns Hopkins Bayview Medical Center.
- Chronic disease
- Quality of care
ASJC Scopus subject areas
- Internal Medicine