Guided Care

Guided Care is a new model of delivering healthcare for older adults with multiple chronic diseases.  Key to this model is the  specially trained Guided Care nurse based in the primary care office.    This nurse “… assesses patient needs, monitors conditions, educates and empowers the patient, and works with community agencies to ensure that the patient’s healthcare goals are met.”

Researchers at Johns Hopkins University, who began developing this model in 2001, are conducting studies and publishing some promising results.   At present CMS does not cover the case management services but there is the possibility that  CMS will begin covering Guided Care as a component of the Medical Home.

The Guided Care website provides describes the model in more detail and provides links to publications.  www.guidedcare.org

Universal Patient Discharge Checklist

Project BOOST, sponsored by the Society of Hospital Medicine,  provides tools to optimize the transition processes from hospital to home or other after care locations. 

This Universal Patient Discharge List is one tool.  J.L. Greenwald provides the following condensed version.

Universal Patient Discharge Checklist

• GAP assessment

• Medications reconciliation

• Medication use and side effects reviewed*

• Confirm understanding of prognosis, self-care, and symptoms requiring immediate medical attention*

• Best Practice guidelines assessment

• Discharge plan completed, taught, and provided to patient/caregiver

• Discharge communication provided to posthospitalization care provider

• Documented receipt of discharge information from principal care providers

*Using Teach Back with patient/caregiver

Transitions of Care

Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine.  J Gen Intern Med.  2009 Apr 3. PMID 19343456.

Other recent articles (click on PMID number for complete citation)

1. Assessing the quality of transitional care: further applications of the care transitions measures.  PMID 18388847.
2. Care transitions for hospitalized patients.  PMID 18298981.
3. The care transitions intervention: results of a randomized controlled trail.  PMID 17000937.
4. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care.  PMID 17327525.
5. Failure at the transition of care: challenges in the discharge of the vulnerable elderly patient.  PMID 18698595.
6. Hospital discharge of older adults.  How nurses can ease the transition.  PMID 17519609.
7. Hospitalists and care transitions: the divorce of inpatient and outpatient care.  PMID 18780917.
8. Improving the complex nature of care transitions; review.  PMID 17873723.
9. Lost in transition:  challenges and opportunities for improving the quality of transitional care.  PMID 15466770.
10. Primary care physicians’ links to other physicians through Medicare patients: the scope of care coordination.  PMID 19221375.
11. Tying up loose ends: discharging patients with unresolved medical issues.  PMID 17592105.