Guided Care: Demonstration Project and Diffusion Planning Johns Hopkins University

Grant Summary

Advancements in chronic disease care are needed for older patients to improve health, promote independence, and reduce hospitalizations. Guided Care is a nurse-coordinated model that brings specially trained RN level nurses into primary care practices to provide and coordinate high quality, evidence-based geriatric care. The John A. Hartford Foundation has made a grant to Johns Hopkins University to co-fund a rigorous demonstration of Guided Care to produce evidence regarding health benefits to patients, feasibility for health systems, and financial outcomes for payers. In partnership with the Agency for Healthcare Research and Quality and the National Institute on Aging, the Foundation hopes to advance the care of older adults with multiple complex chronic diseases. Drawing upon successful innovations in geriatric care, including many developed with Foundation support, such as the IMPACT depression model and the Geriatric Interdisciplinary Team Training, the Guided Care model has been created. In year one, seven nurses will be recruited and trained to provide guided care in collaboration with primary care physicians and a sophisticated software system. In addition, early strategic marketing efforts will be made to facilitate subsequent adoption of this model.