Study Watch: "Guided Care" Health Care Model for Patients with Other Chronic Conditions

Dorian Martin Health Guide
  • Often when I talk with others about my mother, they start to think that Alzheimer's disease is the only major medical issue that Mom faces. I often have to insert in the conversation that my mother also suffers from Chronic Obstructive Pulmonary Disease (brought on from far too many years of smoking) and that her lung capacity is rapidly weakening.


    Taken separately, each disease is a major health issue in itself that provides challenges not only for the person who suffers from it, but for the family members and friends who try to provide support as well as the medical staff who provide treatment. When these two major illnesses are faced at the same time by one person, the complexity of treatment issues as well as coordination can become a logistical medical nightmare.

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    Fortunately, the nursing home's nurses do a good job in trying to stay at the center of Mom's ever-spinning medical Wheel of Fortune and have managed to keep her out of the emergency room (which, when she was in West Texas, was on almost a biweekly basis). Based on Mom's ongoing challenges, I've often wondered what happens in the care of other loved ones who have dementia and another chronic disease. How can their care be effectively coordinated, especially if the loved one still lives at home?


    So it was with great interest that I listened to a radio program produced by AARP this weekend that featured an interview with Dr. Charles Boult from the Johns Hopkins Bloomberg School of Public Health. Dr. Boult currently is leading a two-year controlled trial on a "Guided Care" model. The research website describes Guided Care as "a novel enhancement of the quality and efficiency of health care for people with several chronic conditions."


    How does it work? The website reports, "In the Guided Care teams, a specially prepared registered nurse works closely with 2-5 primary care physicians in caring for their chronically ill older patients. For each Guided Care patient, the nurse conducts an in-home assessment, develops an evidence-based ‘care guide' to address the chronic problems, monitors the patient proactively, coaches the patient in self-management, coordinates the efforts of all health care providers, smoothes the patient's transitions between sites of care, facilitates access to community resources, and educates and supports the family caregivers."


    Dr. Boult and the radio program moderator discussed how this type of model appears to be very effective for a patient who has dementia. I also can see how this type of program would be a godsend to the family members or friends who are trying to provide assistance, but who do not have the medical background to deal with the challenges that Alzheimer's and another chronic disease present.


    As part of his research, Dr. Boult said he also is trying to determine the costs that would be incurred in implementing the Guided Care program to determine feasibility. In just thinking about my mother's case, I'd have to say this program would be cost-effective due to the fact that the service's cost would be offset by the number of emergency room visits that would have been avoided if Mom had this type of support.


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    I'm going to be interested in seeing how this study progresses. You may want to keep an eye on this study, too, and also share this information with your loved one's physician.


    For more information on Guided Care:

Published On: August 27, 2007