Guided Care: A Structured Approach to Providing Comprehensive Primary Care for Complex Patients

Martha Hostetter
Sarah Klein
Douglas McCarthy
Susan L. Hayes
Case Example
October 2016

This resource describes the Guided Care model of care management and its implementation in two health systems: Lahey Health of Burlington, Massachusetts, and Holy Family Memorial of Manitowoc County, Wisconsin. Created by Johns Hopkins University researchers in 2001 and licensed to health care systems, the Guided Care model aims to improve health outcomes and lower health care spending by better managing care for the growing number of aging Americans with multiple chronic conditions.

  • The creators of Guided Care sought to strike a balance between telephone-based care management programs, which are relatively inexpensive but ineffective for high-need patients, and operationally complex programs that rely on interdisciplinary care teams.
  • The model creates a structured process for registered nurses to assess these patients’ needs, create care plans, and teach patients and their caregivers to manage health conditions.
  • Nurses take an online training course to fulfill this role, then work with patients identified in primary care practices. They monitor how patients are doing over time, orchestrate transitions among care settings, and provide referrals to community resources.
  • Guided Care is offered through Johns Hopkins as a licensed program. If 10 or fewer nurses follow the program at one site, the license is $3,000 for three years. Sites with 10 to 49 Guided Care nurses pay about $10,000 for three years, and those with more than 50 Guided Care nurses pay about $50,000 for three years.
  • Lahey Health attributes its recent success in reducing hospital admissions and emergency department visits in part to Guided Care. From 2013, the year it implemented the program, to 2014, the health system’s Medicare ACO beneficiaries had a 22 percent reduction in admission rates, and a 7 percent reduction in emergency department visits. 
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