ABSTRACT
BACKGROUND
Patients at risk for generating high health care expenditures often receive fragmented, low-quality, inefficient health care. Guided Care is designed to provide proactive, coordinated, comprehensive care for such patients.
OBJECTIVE
We hypothesized that Guided Care, compared to usual care, produces better functional health and quality of care, while reducing the use of expensive health services.
DESIGN
32-month, single-blind, matched-pair, cluster-randomized controlled trial of Guided Care, conducted in eight community-based primary care practices.
PATIENTS
The “Hierarchical Condition Category” (HCC) predictive model was used to identify high-risk older patients who were insured by fee-for-service Medicare, a Medicare Advantage plan or Tricare. Patients with HCC scores in the highest quartile (at risk for generating high health care expenditures during the coming year) were eligible to participate.
INTERVENTION
A registered nurse collaborated with two to five primary care physicians in providing eight services to participants: comprehensive assessment, evidence-based care planning, proactive monitoring, care coordination, transitional care, coaching for self-management, caregiver support, and access to community-based services.
MAIN MEASURES
Functional health was measured using the Short Form–36. Quality of care and health services utilization were measured using the Patient Assessment of Chronic Illness Care and health insurance claims, respectively.
KEY RESULTS
Of the eligible patients, 904 (37.8 %) gave written consent to participate; of these, 477 (52.8 %) completed the final interview, and 848 (93.8 %) provided complete claims data. In intention-to-treat analyses, Guided Care did not significantly improve participants’ functional health, but it was associated with significantly higher participant ratings of the quality of care (difference = 0.27, 95 % CI = 0.08–0.45) and 29 % lower use of home care (95 % CI = 3–48 %).
CONCLUSIONS
Guided Care improves high-risk older patients’ ratings of the quality of their care, and it reduces their use of home care, but it does not appear to improve their functional health.
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Acknowledgements
We thank: Wade Kramer, MHSA, and Susan Kim, BS, CPA, of Kaiser Permanente; Paula Norman, BS, of Johns Hopkins HealthCare; and Taneka Lee, BS, of the Lipitz Center for the expert technical assistance they provided in the course of their regular employment. We also thank Constantine Frangakis, PhD, and Thomas Louis, PhD, of the Department of Biostatistics at the Johns Hopkins Bloomberg School of Public Health for contributing their assistance with the statistical analysis.
This study was supported by grants from the Agency for Healthcare Research and Quality, the National Institute on Aging, the John A. Hartford Foundation, and the Jacob and Valeria Langeloth Foundation—and by in-kind contributions from Johns Hopkins HealthCare (administrative and information technology support), Johns Hopkins Community Physicians (clinical office space), Kaiser Permanente Mid-Atlantic States (administrative support and clinical office space), MedStar Physician Partners (clinical office space), and the Roger C. Lipitz Center for Integrated Health Care (administrative support).
None of the supporting organizations had any role in: the design and conduct of the study; the collection, management, analysis or interpretation of the data; or the preparation, review, or approval of the manuscript. Drs. Boult and Scharfstein had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Conflict of Interest
The authors declare that they do not have a conflict of interest.
Disclaimer
The views expressed in this article are Dr. Boult’s and do not necessarily reflect those of PCORI.
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Supported by grants from the Agency for Healthcare Research and Quality, the National Institute on Aging, the John A. Hartford Foundation, and the Jacob and Valeria Langeloth Foundation—and by in-kind contributions from Johns Hopkins HealthCare, Johns Hopkins Community Physicians, Kaiser Permanente Mid-Atlantic States, MedStar Physician Partners, and the Roger C. Lipitz Center for Integrated Health Care.
Clinical Trials.gov ID# NCT0012194
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Boult, C., Leff, B., Boyd, C.M. et al. A Matched-Pair Cluster-Randomized Trial of Guided Care for High-Risk Older Patients. J GEN INTERN MED 28, 612–621 (2013). https://doi.org/10.1007/s11606-012-2287-y
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DOI: https://doi.org/10.1007/s11606-012-2287-y