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J Gen Intern Med. 2013 May;28(5):612-21. doi: 10.1007/s11606-012-2287-y.

A matched-pair cluster-randomized trial of guided care for high-risk older patients.

Author information

1
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. cboult@jhsph.edu

Abstract

BACKGROUND:

Patients at risk for generating high health care expenditures often receive fragmented, low-quality, inefficient health care. Guided Care is designed to provide proactive, coordinated, comprehensive care for such patients.

OBJECTIVE:

We hypothesized that Guided Care, compared to usual care, produces better functional health and quality of care, while reducing the use of expensive health services.

DESIGN:

32-month, single-blind, matched-pair, cluster-randomized controlled trial of Guided Care, conducted in eight community-based primary care practices.

PATIENTS:

The "Hierarchical Condition Category" (HCC) predictive model was used to identify high-risk older patients who were insured by fee-for-service Medicare, a Medicare Advantage plan or Tricare. Patients with HCC scores in the highest quartile (at risk for generating high health care expenditures during the coming year) were eligible to participate.

INTERVENTION:

A registered nurse collaborated with two to five primary care physicians in providing eight services to participants: comprehensive assessment, evidence-based care planning, proactive monitoring, care coordination, transitional care, coaching for self-management, caregiver support, and access to community-based services.

MAIN MEASURES:

Functional health was measured using the Short Form-36. Quality of care and health services utilization were measured using the Patient Assessment of Chronic Illness Care and health insurance claims, respectively.

KEY RESULTS:

Of the eligible patients, 904 (37.8 %) gave written consent to participate; of these, 477 (52.8 %) completed the final interview, and 848 (93.8 %) provided complete claims data. In intention-to-treat analyses, Guided Care did not significantly improve participants' functional health, but it was associated with significantly higher participant ratings of the quality of care (difference = 0.27, 95 % CI = 0.08-0.45) and 29 % lower use of home care (95 % CI = 3-48 %).

CONCLUSIONS:

Guided Care improves high-risk older patients' ratings of the quality of their care, and it reduces their use of home care, but it does not appear to improve their functional health.

PMID:
23307395
PMCID:
PMC3631081
DOI:
10.1007/s11606-012-2287-y
[Indexed for MEDLINE]
Free PMC Article
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