Clinical Features of High-Risk Older Persons Identified by Predictive Modeling

Sylvia, Martha; Shadmi, Efrat; Hsiao, Chun Ju; Boyd, Cynthia M.; Schuster, Alyson; Boult, Chad

doi:10.1089/dis.2006.9.56

Cited by 23 publications

(24 citation statements)

References 12 publications

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“…As reported elsewhere (Sylvia et al, 2006), the patients identified for this pilot test of Guided Care had multimorbidity (M ¼ 3.0 chronic conditions per person) and functional disability (36% had difficulty performing activities of daily living, 58% had difficulty performing instrumental activities of daily living), and they had generated high insurance expenditures for health care (M ¼ $22,800 per person per year).…”

Section: From October 2003mentioning

confidence: 65%

Guided Care for Multimorbid Older Adults

Boyd¹,

Boult²,

Shadmi³

et al. 2007

The Gerontologist

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Purpose: The purpose of this study was to test the feasibility of a new model of health care designed to improve the quality of life and the efficiency of resource use for older adults with multimorbidity. Design and Methods: Guided Care enhances primary care by infusing the operative principles of seven chronic care innovations: disease management, self-management, case management, lifestyle modification, transitional care, caregiver education and support, and geriatric evaluation and management. To practice Guided Care, a registered nurse completes an educational program and uses a customized electronic health record in working with two to five primary care physicians to meet the health care needs of 50 to 60 older patients with multimorbidity. For each patient, the nurse performs a standardized comprehensive home assessment and then collaborates with the physician, the patient, and the caregiver to create two comprehensive, evidencebased management plans: a Care Guide for health care professionals, and an Action Plan for the patient and caregiver. Based in the primary care office, the nurse then regularly monitors the patient's chronic conditions, coaches the patient in self-management, coordinates the efforts of all involved health care professionals, smoothes the patient's transitions between sites of care, provides education and support for family caregivers, and facilitates access to community resources. -Results: A 1-year pilot test in a community-based primary care practice suggested that Guided Care is feasible and acceptable to physicians, patients, and caregivers. Implications: If successful in a controlled trial, Guided Care could improve the quality of life and efficiency of health care for older adults with multimorbidity.

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