Purpose: This article describes “Guided Care,” a promising new model of case management that includes disease management, self-management, transitional care, and caregiver support for multimorbid patients and their families.
Primary Practice Settings: Guided Care nurses, based at primary care practices, extend services to the home and all the other settings where their patients receive care.
Findings and Conclusions: Guided Care nurses take responsibility for 50—60 multimorbid patients. For each patient, the nurse performs a home assessment and creates an evidence-based plan of care. In partnership with the primary physician, the Guided Care nurse then monitors and coaches the patient monthly, coordinates the patient's transitions between providers and sites of care, educates and supports family caregivers, and facilitates access to community resources.
Implications for Case Management Practice: As a next stage in the evolution of case management, Guided Care may be supported by Medicare and, therefore, adopted widely throughout the American healthcare.
Sherry L. Aliotta, BSN, RN, CCM, is president and CEO of S.A. Squared of Tennessee, Inc. Sherry founded this company in 1997 to specialize in all aspects of medical management. Her company has worked with hospitals, health plans, universities, physician groups, CMS, Grantors, and publishers. Her case management experience spans over 21 years from the frontline to vice president of a health plan. She speaks and publishes widely both in the United States and in other areas of the world. She served as the national president of Case Management Society of America (CMSA) during 2004–2005 and was a National Board member for 3 years before her election as president. Her work on the Council for Case Management Accountability and the Case Management Adherence Guidelines supports her passion for establishing credible case management outcomes. In 1996, CMSA named Sherry the “Distinguished Case Manager of the Year.”
Kathleen Grieve, RN, BSN, MHA, CCM, is a Guided Care nurse with more than 15 years experience in nursing, healthcare administration, and case and disease management.
Jean F. Giddens, PhD, RN, is an associate professor and concentration coordinator for Graduate Nursing Education at the University of New Mexico College of Nursing. Areas of expertise include student-centered teaching strategies, learner engagement, online learning applications, and curriculum development. Intellectual Contributions: Giddens collaborated with development and evaluation of the Guided Care education program (for nurses), facilitated understanding and articulation of professional nursing role within the GC model, and provided suggestions to manuscript organization and presentation.
Linda Dunbar, PhD, RN, is the vice president of Care Management for Johns Hopkins HealthCare. Since 1997, she has designed and implemented disease management programs for eight diagnoses. She received a B.S. in nursing from Towson University and an M.S. and Ph.D. in nursing and health policy from the University of Maryland.
Carol Groves, RN, is the director of Senior Services for Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. Her specialty areas include quality and utilization improvement and development and management of elder care programs. She received a B.S.N. from Texas Woman's University and an M.P.A. from New York University.
Katherine Frey, MPH, is a research associate at the Johns Hopkins University Bloomberg School of Public Health, with more than 7 years of project management experience. Her research interests include geriatrics, self-management, and traumatic injury. Contributions: Katherine Frey served as the project director during the implementation of the Guided Care study. She played key roles in determining how nurses would integrate into practices and what the key attributes of the Guided Care nurses would be. She actively participated in the development of the orientation to Guided Care. She was involved in the hiring and management of the GCNs. She managed the selection and training of chronic-disease self-management leaders and served as a leader herself. She also served as a member of a small team responsible for responding to mid-course corrections that were required as the intervention was implemented.
Chad Boult, MD, MPH, MBA, is the Roger C. Lipitz Professor of Public Health, and he holds joint appointments on the faculties of the Johns Hopkins University Schools of Medicine and Nursing. He directs the Roger C. Lipitz Center for Integrated Health Care at the Johns Hopkins Bloomberg School of Public Health.
Address correspondence to Sherry L. Aliotta, BSN, RN, CCM, S.A. Squared of Tennessee, Inc., Evansville, IN 47701 (firstname.lastname@example.org).
The authors have no conflict of interest.