Improving Chronic Care: The “Guided Care” Model

Everyone is working hard, but the quality of chronic care is still mediocre. Donald Berwick, MD, says “every system is designed perfectly to achieve the results that it achieves.”1 The problem is the growing mismatch between the chronic care needs of the population and the acute care orientation of the health care system. Sixty-five million older people with multiple chronic conditions are trying to get health care from a system that is designed to treat acute illnesses and injuries. It's as though we are trying to put a square peg in a round hole. We will continue to get the poor results we are now getting until we redesign the system. Guided Care is a new model for “chronic care” that is now being tested by Kaiser Permanente (KP) in the Baltimore-Washington, DC area. Guided Care is primary health care infused with the operative principles of recent innovations to ensure optimal outcomes for patients with chronic conditions and complex health care needs. A registered nurse who has completed a supplemental educational curriculum works in a practice with several primary care physicians, conducting eight clinical processes for 50–60 multimorbid patients. A Typical Case Ms Marian Chen is a 79-year-old widow who lives alone. She receives Social Security benefits and a modest pension; she is enrolled in a KP Medicare Health Plan. Her daughter lives ten miles away and is busy dealing with her three teenagers. Ms Chen has five chronic conditions for which she sees three physicians and takes eight prescription medications every day. The patient has had a very busy and medically complex year. She has seen eight physicians, five physical therapists, four occupational therapists, 37 nurses, and six social workers. This was the result of her chronic conditions flaring up and causing two hospitalizations, followed by inpatient postacute care and home care (Figure 1). At each transition, a new team of clinicians assessed the patient and created a new care plan. Figure 1 A year in the patient's life … Despite her insurance coverage, the patient has incurred significant out-of-pocket costs, increasing her stress level. The patient rates her quality of life as poor. Her daughter, to help, has reduced her workload to half-time, and is now considering nursing home options for her mother. She doesn't think she can keep doing this much longer. The family's experiences, which are not unusual, show that chronic care is: fragmented discontinuous difficult to access inefficient unsafe expensive.