Guided care for multimorbid older adults

Cynthia Boyd, Chad Boult, Efrat Shadmi, Bruce A Leff, Rosemarie Brager, Linda Dunbar, Jennifer Wolff, Stephen T Wegener

Research output: Contribution to journalArticle

Abstract

Purpose: 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. Design and 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. Implications: If successful in a controlled trial, Guided Care could improve the quality of life and efficiency of health care for older adults with multimorbidity.

Original languageEnglish (US)
Pages (from-to)697-704
Number of pages8
JournalGerontologist
Volume47
Issue number5
StatePublished - Oct 2007

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Caregivers
Delivery of Health Care
Comorbidity
Primary Health Care
Nurses
Self Care
Quality of Life
Physicians
Education
Patient Transfer
Electronic Health Records
Case Management
Primary Care Physicians
Disease Management
Geriatrics
Life Style

Keywords

  • Chronic disease
  • Multimorbidity
  • Nursing
  • Primary care

ASJC Scopus subject areas

  • Aging

Cite this

Boyd, C., Boult, C., Shadmi, E., Leff, B. A., Brager, R., Dunbar, L., ... Wegener, S. T. (2007). Guided care for multimorbid older adults. Gerontologist, 47(5), 697-704.

Guided care for multimorbid older adults. / Boyd, Cynthia; Boult, Chad; Shadmi, Efrat; Leff, Bruce A; Brager, Rosemarie; Dunbar, Linda; Wolff, Jennifer; Wegener, Stephen T.

In: Gerontologist, Vol. 47, No. 5, 10.2007, p. 697-704.

Research output: Contribution to journalArticle

Boyd, C, Boult, C, Shadmi, E, Leff, BA, Brager, R, Dunbar, L, Wolff, J & Wegener, ST 2007, 'Guided care for multimorbid older adults', Gerontologist, vol. 47, no. 5, pp. 697-704.
Boyd C, Boult C, Shadmi E, Leff BA, Brager R, Dunbar L et al. Guided care for multimorbid older adults. Gerontologist. 2007 Oct;47(5):697-704.
Boyd, Cynthia ; Boult, Chad ; Shadmi, Efrat ; Leff, Bruce A ; Brager, Rosemarie ; Dunbar, Linda ; Wolff, Jennifer ; Wegener, Stephen T. / Guided care for multimorbid older adults. In: Gerontologist. 2007 ; Vol. 47, No. 5. pp. 697-704.
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