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A Pilot Test of the Effect of Guided Care on the Quality of Primary Care Experiences for Multimorbid Older Adults

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Abstract

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.

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References

  1. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348:2635–45.

    Article  PubMed  Google Scholar 

  2. Anderson G, Horvath J. Chronic Conditions: Making the Case for Ongoing Care. Baltimore, MD: Partnership for Solutions; 2002.

    Google Scholar 

  3. Gruenberg L, Tompkins C, Porell F. The health status and utilization patterns of the elderly: implications for setting Medicare payments to HMOs. Adv Health Econ Health Serv Res. 1989;10:41–73.

    PubMed  CAS  Google Scholar 

  4. Boult C, Boult LB, Morishita L, Dowd B, Kane RL, Urdangarin CF. A randomized clinical trial of outpatient geriatric evaluation and management. J Am Geriatr Soc. 2001;49:351–9.

    Article  PubMed  CAS  Google Scholar 

  5. Reuben DB, Frank JC, Hirsch SH, McGuigan KA, Maly RC. A randomized clinical trial of outpatient comprehensive geriatric assessment coupled with an intervention to increase adherence to recommendations. J Am Geriatr Soc. 1999;47:269–76.

    PubMed  CAS  Google Scholar 

  6. Cohen HJ, Feussner JR, Weinberger M, et al. A controlled trial of inpatient and outpatient geriatric evaluation and management. N Engl J Med. 2002;346:905–12.

    Article  PubMed  Google Scholar 

  7. Leveille SG, Wagner EH, Davis C, et al. Preventing disability and managing chronic illness in frail older adults: a randomized trial of a community-based partnership with primary care. J Am Geriatr Soc. 1998;46:1191–8.

    PubMed  CAS  Google Scholar 

  8. Unutzer J, Katon W, Callahan CM, et al. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA. 2002;288:2836–45.

    Article  PubMed  Google Scholar 

  9. Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281:613–20.

    Article  PubMed  CAS  Google Scholar 

  10. Mittelman MS, Ferris SH, Shulman E, Steinberg G, Levin B. A family intervention to delay nursing home placement of patients with Alzheimer disease. A randomized controlled trial. JAMA. 1996;276:1725–31. [see comments].

    Article  PubMed  CAS  Google Scholar 

  11. Coleman EA, Mahoney E, Parry C. Assessing the quality of preparation for posthospital care from the patient’s perspective: the care transitions measure. Med Care. 2005;43:246–55.

    Article  PubMed  Google Scholar 

  12. Lorig KR, Sobel DS, Stewart AL, et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial. Med Care. 1999;37:5–14.

    Article  PubMed  CAS  Google Scholar 

  13. Lorig KR, Ritter P, Stewart AL, et al. Chronic disease self-management program: 2-year health status and health care utilization outcomes. Med Care. 2001;39:1217–23.

    Article  PubMed  CAS  Google Scholar 

  14. Phelan EA, Williams B, Leveille S, Snyder S, Wagner EH, LoGerfo JP. Outcomes of a community-based dissemination of the health enhancement program. J Am Geriatr Soc. 2002;50:1519–24.

    Article  PubMed  Google Scholar 

  15. Phelan EA, Williams B, Penninx BW, LoGerfo JP, Leveille SG. Activities of daily living function and disability in older adults in a randomized trial of the health enhancement program. J Gerontol A Biol Sci Med Sci. 2004;59:838–43.

    PubMed  Google Scholar 

  16. Bodenheimer T. Disease management in the American market. BMJ. 2000;320:563–6.

    Article  PubMed  CAS  Google Scholar 

  17. Ofman JJ, Badamgarav E, Henning JM, et al. Does disease management improve clinical and economic outcomes in patients with chronic diseases? A systematic review. Am J Med. 2004;117:182–92.

    Article  PubMed  Google Scholar 

  18. Badamgarav E, Weingarten SR, Henning JM, et al. Effectiveness of disease management programs in depression: a systematic review. Am J Psychiatry. 2003;160:2080–90.

    Article  PubMed  Google Scholar 

  19. Boult C, Rassen J, Rassen A, Moore RJ, Robison S. The effect of case management on the costs of health care for enrollees in Medicare Plus Choice plans: a randomized trial. J Am Geriatr Soc. 2000;48:996–1001.

    PubMed  CAS  Google Scholar 

  20. Rich MW, Beckham V, Wittenberg C, Leven CL, Freedland KE, Carney RM. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med. 1995;333:1190–5.

    Article  PubMed  CAS  Google Scholar 

  21. Eng C, Pedulla J, Eleazer GP, McCann R, Fox N. Program of All-inclusive Care for the Elderly (PACE): an innovative model of integrated geriatric care and financing. J Am Geriatr Soc. 1997;45:223–32.

    PubMed  CAS  Google Scholar 

  22. Newcomer R, Harrington C, Kane R. Implementing the second generation social health maintenance organization. J Am Geriatr Soc. 2000;48:829–34.

    PubMed  CAS  Google Scholar 

  23. The MacColl Institute. The Care Model: Expanded Chronic Care Model. Available at: http://www.improvingchroniccare.org/index.php?p=Graphics&s=164. Accessed January 9, 2008.

  24. Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract. 1998;1:2–4.

    PubMed  CAS  Google Scholar 

  25. Ash AS, Ellis RP, Pope GC, et al. Using diagnoses to describe populations and predict costs. Health Care Financ Rev. 2000;21:7–28.

    PubMed  CAS  Google Scholar 

  26. White JV, Dwyer JT, Posner BM, Ham RJ, Lipschitz DA, Wellman NS. Nutrition screening initiative: development and implementation of the public awareness checklist and screening tools. J Am Diet Assoc. 1992;92:163–7.

    PubMed  CAS  Google Scholar 

  27. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189–98.

    Article  PubMed  CAS  Google Scholar 

  28. Podsiadlo D, Richardson S. The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39:142–8.

    PubMed  CAS  Google Scholar 

  29. Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res. 1982;17:37–49.

    Article  PubMed  Google Scholar 

  30. Mayfield D, McLeod G, Hall P. The CAGE questionnaire: validation of a new alcoholism screening instrument. Am J Psychiatry. 1974;131:1121–3.

    PubMed  CAS  Google Scholar 

  31. Bennett JA, Perrin NA, Hanson G, et al. Healthy aging demonstration project: nurse coaching for behavior change in older adults. Res Nurs Health. 2005;28:187–97.

    Article  PubMed  Google Scholar 

  32. Boyd CM, Boult C, Shadmi E, et al. Guided care for multimorbid older adults. Gerontologist. 2007;47:697–704.

    PubMed  Google Scholar 

  33. Weiner JP, Abrams C, Bodycombe D. The Johns Hopkins ACG Case-Mix System, Version 6 Release Notes. Available at: http://www.acg.jhsph.edu/. Accessed January 17, 2008.

  34. Sylvia ML, Shadmi E, Hsiao CJ, Boyd CM, Schuster AB, Boult C. Clinical features of high-risk older persons identified by predictive modeling. Dis Manag. 2006;9:56–62.

    Article  PubMed  Google Scholar 

  35. Safran DG, Kosinski M, Tarlov A, et al. The Primary Care Assessment Survey: tests of data quality and measurement performance. Med Care. 1998;36:728–39.

    Article  PubMed  CAS  Google Scholar 

  36. Weiss RE. Modeling Longitudinal Data. New York, NY: Springer; 2005.

    Google Scholar 

  37. Diggle PJ, Heagerty P, Liang K-Y, Zeger S. Analysis of Longitudinal Data. London: Oxford University Press; 2002.

    Google Scholar 

  38. Sofaer S, Firminger K. Patient perceptions of the quality of health services. Annu Rev Public Health. 2005;26:513–59.

    Article  PubMed  Google Scholar 

  39. Institute of Medicine. Crossing the Quality Chasm: a New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.

    Google Scholar 

  40. Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005;294:716–24.

    Article  PubMed  CAS  Google Scholar 

  41. Werner RM, Greenfield S, Fung C, Turner BJ. Measuring quality of care in patients with multiple clinical conditions: Summary of a conference conducted by the society of general internal medicine. J Gen Intern Med. 2007;2281206–11.

    Article  PubMed  Google Scholar 

  42. American Nurses Association: Nursing’s agenda for the future. Available at: http://nursingworld.org/MainMenuCategories/HealthcareandPolicyIssues/Reports/AgendafortheFuture.aspx. Accessed January 9, 2008.

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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.

Conflict of Interest

None disclosed.

Author information

Authors and Affiliations

  1. Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Cynthia M. Boyd MD, MPH, Bruce Leff MD & Chad Boult MD, MPH, MBA

  2. Roger C. Lipitz Center for Integrated Health Care, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

    Cynthia M. Boyd MD, MPH, Leslie Jackson Conwell PhD, Bruce Leff MD & Chad Boult MD, MPH, MBA

  3. The Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel

    Efrat Shadmi RN, PhD

  4. Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

    Michael Griswold PhD

  5. Johns Hopkins University School of Nursing, Baltimore, MD, USA

    Rosemarie Brager CRNP, PhD

  6. Johns Hopkins HealthCare, Baltimore, MD, USA

    Martha Sylvia RN, MSN, MBA

Authors
  1. Cynthia M. Boyd MD, MPH
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  2. Efrat Shadmi RN, PhD
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  3. Leslie Jackson Conwell PhD
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  4. Michael Griswold PhD
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  5. Bruce Leff MD
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  6. Rosemarie Brager CRNP, PhD
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  7. Martha Sylvia RN, MSN, MBA
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  8. Chad Boult MD, MPH, MBA
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Corresponding author

Correspondence to Cynthia M. Boyd MD, MPH.

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Boyd, C.M., Shadmi, E., Conwell, L.J. et al. A Pilot Test of the Effect of Guided Care on the Quality of Primary Care Experiences for Multimorbid Older Adults. J GEN INTERN MED 23, 536–542 (2008). https://doi.org/10.1007/s11606-008-0529-9

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  • DOI: https://doi.org/10.1007/s11606-008-0529-9

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