The “Guided Care” Model Shows Promise

by Mariluz Billoch
March 22nd, 2011

Picked up this article off our Google Reader feed and had to share it!

Guided Care is a model of proactive, comprehensive health care provided by physician-nurse teams for people with several chronic health conditions. Primary care practices can adopt Guided Care to help become patient-centered medical homes or accountable care organizations. The model is designed to improve quality of care and quality of life, while improving the efficiency of treating the sickest and most complex patients. Guided Care teams consist of a registered nurse, two to five physicians, and the other members of the primary care office staff who work together for the benefit of each patient to:

Assess the patient and family caregiver at home

Create an evidence-based ‘Care Guide’ (care plan) and patient-friendly ‘Action Plan’

Monitor the patient’s conditions monthly

Promote patient self-management

Coordinate the efforts of all the patient’s healthcare providers

Smooth the patient’s transition between sites of care

Inform and support family caregivers

For more information about Guided Care, please visit http://www.GuidedCare.org [read full post here]

This model as well as others that strive to create a holistic approach to care transitions will continue to evolve as new means to rid off our current fragmented delivery systems emerge. I for one get behind any model that effectively addresses and improves communications across the care continuum for patients and families.

Stay close for future posts on this topic! :-)