Hi everyone, and welcome to the Guided Care course!  

I will be the course facilitator, and I look forward to getting to know you as we move through the exciting content in this course.  I say "facilitator" instead of "instructor," because 1) you all come to this course with background experience that makes you an expert on taking care of the kinds of patients we see in Guided Care, and 2) we will be using the webinars as an opportunity to interact and role play around the kinds of scenarios Guided Care Nurses experience in their day-to-day lives, and you will get the most out of the course if you participate.

I have been working with Guided Care since the randomized trial to evaluate its effectiveness, when I was the study project director.  I believe strongly that the GC model can make an enormous difference in the lives of vulnerable, older patients.  I appreciate the commitment you are making to this population through taking this course.

On a personal note, I am still working in research, this time in orthopedic trauma.  I am married, and we have 2 kids, a 10 and 8 year old, and a little yappy dog (who you may hear during our webinars :) Sorry!).  In my free time I enjoy hiking, reading, and cooking.

How about you? Please reply to this thread to tell me about yourself.


Katherine Frey replied on

Hi Katherine--

I am looking over the course site and wanted to answer your personal note. First off--looking forward the course and learning new things!  I am a long time nurse with a background in oncology, home care, wound care and hospice--I just left hospice to take the Care Manager position as the on call and time away from my daughter was too much.  I am a single mom and my daughter is 15 and her name is Sarah--she is a freshman and we are active in volunteer work in Haiti which is her birth country--she most recently designed a 40 page coloring book for children and we have printed 1000 and already 600 are spoken for in Haiti and 200 are going to Africa!  Talk to you soon, Susan

Susan Cain replied on

Welcome, Susan!  I'm looking forward to getting to know you better, and I hope this course is able to help you transition into your new role.  Your daughter sounds like an amazing kid!

Katherine Frey replied on

Hi Katherine,

Thank you for the introduction! I am a nurse of 14 years with a backround in homecare. I transitioned about a year ago to case management in an office setting due to the on call and weekend requirements of homecare. I have two kids ages 14 and 6 and a miniture schnauzer. In my free time I enjoy running, cycling, hanging with my family and reading.


Starr Vinyard replied on

Welcome to the course!  I am sure your homecare background will help you enormously with transitioning to this role.  I look forward to hearing about your experiences and learning from you.  

Katherine Frey replied on


I am very excited to be taking this course!  My path is a bit different ~ I am currently the Benefits and Wellness Manager of a large retail mail order company.  I began my job there 15 years ago as the occupational health nurse and have transitioned into more of a managerial role.  I am taking this course in anticipation of working with my local County Health Department and practitioners.  I feel so fortunate to be a part of this class, and I am looking forward to learning!

We have three children (2 girls and a boy), two are married and our youngest daughter is in her last year of college.  My older daughter is also a nurse :)  We have 2 pugs, a golden retriever, and a kitten...I know, my husband thinks this is too many animals too...but, I just love them!  I believe in practicing the healthy lifestyle that I preach, so I am a fitness instructor, a runner (with my partner Zen, the golden retriever), and a lover of healthy foods! 

I am confident that we are going to learn information and skills that will help make a difference in people's lives. 

Can't wait to get started!


Shelly Wells replied on

Hi Shelly - glad to have you in our group.  We will appreciate your managerial perspective as we move forward through the course.  Looking forward to hearing about your experiences.  And 4 animals doesn't sound like too many :)

Katherine Frey replied on


I'm excited to be taking the Guided Care Course.  I have been working with an IM/PEDS provider for about 13 years with additional experience in Geriatrics/Assisted Living/Rehab/L&D.  This is my first on-line course and hope I'm computer savvy enough to participate in the webinars.

I have 2 children ages 21 & 23, along with 6 pets (3 dogs, 2 cats, and a rabbit).  I enjoy crocheting blankets and hats for patients, reading, cooking. 

Looking forward to this experience.


Doreen Morgan replied on

Hi Doreen - welcome to the course!  You were savvy enough to find the discussion board - I'm sure you'll be able to find the webinars :)  Let me know if you have any trouble finding the course content (called "courses" on the main page), as that's where all independent learning activities are.

Katherine Frey replied on

Having issues getting into a couple courses (3, 18, 19, 20), access denied.  trying to access and print information.

Doreen Morgan replied on

If you are having technical problems, please contact the IJHN.  They should be able to help you out.

Katherine Frey replied on

Only the first day and I goofed - my introduction is at the bottom of the whole page. I was so intent on reading everyone's replies, I started typing in the comment box at the end instead of replying to this one!


Lauryn Mitchell replied on

it happens all the time!

Katherine Frey replied on

Hi, Katherine,

I've been a nurse for 37 years in Southern California, initially cardiac and medical intensive care, transitioning to home health and community-based services for the past 25 years.  I supervise the nurses in our department in addition to running a community health education program, the 50+ Health Connection.  My passion is involved in end-of-life care education.  I chair our local end-of-life care coalition and am on the governing board for our statewide end-of-life care organization based in Sacramento.  I'm a single mother of twin daughters who are sophmores in college - Pennsylvania and Wisconsin.  I became interested in this course as our hospital focus on care transitions and community-based services is growing.  As a designated magnet nursing hospital, this is the first course through ANCC in line with my work.  I'm excited that this is being offered!  In my free time, I'm enjoying a mystery book club, something I never had time for when my daughters were growing up.  What fun!


Patricia Watson-Wood replied on

Hi Patty - glad to have you in the course.  I'm interested in hearing about your experiences, and I hope this course will help you provide guidance to your hospital around transitional care experiences.  Also interested in your book recommendations :)

Katherine Frey replied on

Hello Katherine,

I am a nurse care manager in an ACO and fairly new to this position here. I worked as a care manager in an MCO for 4 years prior to coming to the ACO.  I have been an RN for 30 years working in various positions in acute care prior to care management.

Looking forward to an interesting 6 weeks.


Cheryl Laneve replied on

Welcome, Cheryl.  I hope this course is able to give you the tools you need to help with your new postion.  I'm sure your past experiences will also be a valuable resource!  Looking forward to getting to know you better.

Katherine Frey replied on

Hello Nurses-

 I am a new nurse (about to hit the one year mark),  working in a clinical setting in a small, rural town in N CA.  Our pt population is very challenging, with high rates of chronic diseases, mental illness and addiction. My job ("RN Care Manager") consists of triage, case management, direct patient care, pt education,  and population management. Many of the topics in this course line up with the principles of care our clinic is striving to provide so I am looking forward to applying the lessons to my daily work.



Brandy Hinrichs replied on

Hi Brandy- glad to have you in our group!  I am sure you will learn many skills which will help you with your patient population.  As a new nurse, if you plan to sit for the exam, please be sure you also complete the supplemental courses on chronic diseases.  They are a GREAT review of these kinds of patients, as well as best practices and interventions that are consisten with the philosophy of Guided Care.  Looking forward to getting to know you better.

Katherine Frey replied on

I have been a nurse for 10 years now, and have a wide variety of experiences.  I am currently working as the DON for a 61 bed nursing home as well as running a Certified Palliative Care Program.  I also have the role of Nurse Informatics.  In the past I have worked in acute care settings (ICU, ER, Neuro/Trauma), Subacute Rehab, and Homecare.  I look forward to this course and I am hoping to enhance my skills/knowledge for caring for our Geriatric population that is so chronically ill.  I am married with 2 children (4 yr old boy and 8 month old girl) and have 3 miniature schnauzers.  In my free time (which is not much) I enjoy running, cooking, and grooming dogs.

Lindsay Garland replied on

It's great to meet you - thanks for the introduction!  I am confident that this course will give you some usefull skills for your current (and future!) roles!

Katherine Frey replied on

Hi everyone – Please refer to this post, as well as the unit summaries I will post, if you are feeling overwhelmed by the amount of content or what you are supposed to turn in at any given point.  The course, as you can see from the main page, is organized into 4 units, each with several modules, and a series of supplemental modules.  The supplemental modules contain critical content, and you are highly encouraged to work through them at your own place, although a webinar will not be specifically devoted to this content.  This material is, however, woven throughout the course and WILL be covered in the GC exam.

 Each week, you should try to listen to all of the recorded lectures found in modules and complete any associated independent learning activities to prepare for the weekly webinar, which usually occur on Thursdays, except where otherwise noted.

Getting to Know You Webinar - 11/14 - We'll just introduce ourselves and get used to the online "Classroom."

Week 1 (now-11/21):  In the first unit, which you should complete in week 1, you will be introduced to some of the basic principles of Guided Care and the skills necessary to function as a GCN, and we will complete  a webinar (11/21) to talk about some of our first impressions and practice some of these skills. 

Week 2 (11/22-11/25): In unit 2 you will learn about how to enroll a patient/caregiver into the GC program, and we will complete a webinar (MONDAY 11/25) to talk through this process and do a few role plays that will help cement the concepts. 

Weeks 3-4 (11/26-12/12): Unit 3 focuses on ongoing GC, and you have two weeks to complete the unit.  Because this is an important unit, 2 webinars, 12/5 & 12/12 will be devoted to this content.  Again, we will use the webinars to practice the skills necessary to successfully conduct ongoing GC.

Week 5: (12/13-12/18): The last unit focuses on integrating into your practice environment.  The final webinar (WEDS 12/18) will be a chance to reflect on what you learned and spend some time thinking about how you will implement the GC model in your current practice environment.

We will hold a review webinar 12/19 for those of you planning to sit for the GC Certificate exam.

Please note: The first 2 weeks are really activity heavy, but then the assignments taper off dramatically.  If you get behind, do not fret!  You can submit assignments throughout the course, and I’ll give you feedback.  Ideally, you will get through all the lectures (even if you are behind on activities) by the time of the webinar.

Submitting assignments:  Except for the Action Plans in Unit 2, please submit all assignments to a discussion board thread I will set up specifically for that assignment.  This makes it easy for me to keep track of who I’ve responded to, and prevents me from accidentally missing anyone. The unit 2 action plans can be submitted to my email,

The webinars are SO MUCH MORE INTERESTING when you participate.  Some people may be a little uncomfortable putting themselves out there at first, but remember, this is a non-judgmental environment, and we are here to help one another learn.  You will only get out of this course what you put into it, so please, consider participating actively.  Also, this will prevent you from getting sick of listening to me :) !

Katherine Frey replied on

My name is Susan and I have been a registered nurse for 30 years.  I have experiences as a float staff nurse, auditing, home health, utilization review, case management, bed management.  I have 20 years of urgent care experience and for the last 2 years have been the clinical supervisor for two urgent cares.  I was intrigued by the posting of a guided care nurse and decided to go down this path to see what I might learn as well as bring to others.  Looking forward to any new and exciting information.  Thank you.


Susan Stanfield replied on

Hi Susan - I am sure that you will learn some new skills in this course, and build on your already substantial knowledge!  Welcome!

Katherine Frey replied on


I have been a nurse for 18 years, just moved to Baltimore, and am working as a Transition Guide. I have experience in acute care, education, long term care, and home care. I look forward to getting to know all of you.


dawn sagliani replied on

Course 1: Overview of GC – Listen to lecture, read up on the “yearbook” of GC patients who you will encounter throughout the course. NOTHING TO SUBMIT.

Course 2: Patient Preferences – Listen to lecture, explore advanced directives for your state.  NOTHING TO SUBMIT.


Course 4: Communicating with providers – Listen to lecture.  Listen to Jeanne Paley’s story.  WRITE A SHORT REPORT ON WHAT IS GOING ON WITH THE PATIENT USING THE TECHNIQUES OF SBAR (Situation, Background, Assessment, and Recommendation) AND POST TO THE THREAD CREATED FOR THIS EXERCISE.

Course 5: Clinical Decision Making - Listen to lecture.  NOTHING TO SUBMIT.


Course 7: Health Information Technology – Listen to lecture. NOTHING TO SUBMIT.

Webinar 1 (11/21): Talk about first impression of GC, review elements of SBAR, discuss use of HIT in your practice.  Practice motivational interviewing.

Katherine Frey replied on

The Guided Care Nurse used all the elements of MI:

Open-ended questions: "How's that going?" (with regard to salt intake in diet) which got the conversation towards barriers from making this happen, ie. lifestyle, meals on wheel, etc.

Affirmation/validation: GCN commented on how thoughtful patient is towards his wife. Stating how important wife was to the patient. "Not wanting to be a burden for his wife."

Reflections: Regarding patient's belief towards exercising and his enegry levels. GCN let patient know that doing a little exercise daily would increase his energy level in the long term, rather than decrease it.

Summary: At the end of the conversation, it was agreed upon to update patient's action plan to include walking to the mailbox 3x/week and to talk with his wife about cooking home more often during the week.

Brandy Hinrichs replied on

Summarizing statements by the GCN for Russell Jackson:

You’re concerned about being a burden to Marlene.

You’re not ready to jump to Meals on Wheels right yet.  You’d like to talk over options for cooking a low salt diet with Marlene first.

You really adore your wife, your “little sweetheart” and you worry about causing her any undue concern.

It’s hard to see that small amounts of exercising will actually reduce your feeling of being so tired all the time.

You’re ready to adjust your action plan to start walking to the mailbox 3 times a week to see how that goes.

Patricia Watson-Wood replied on

Hi Patty - This is a great example of summarizing statements, and you successful touched on all the main points of the conversation.  I especially like your attention to the things he said he was willing to do, for example walking, talking about a low salt diet.  One thing you could add would be to finalize the conversation by stating what you will do, what he will do, and when you will next touch base, to turn the summary into a mini-action plan.

Katherine Frey replied on

The GCN used the elements of motivational interviewing to assist Russell Jackson in making positive changes to benefit his disease management.

Open-ended questions: "It sounds like you are worried about being a burden to your wife?"

Affirmation: "Your wife is very special and important to you"

Reflection: "you are worried about exercising more because you want enough energy to spend time with your wife when she gets home from work"

Summery: "walking to the mailbox everyday is something you feel you will be able to accomplish three times a week lets update your action plan to reflect that"

Starr Vinyard replied on

Nice job identifying the use of OARS in this interaction.  Thinking about your patients, can you imagine using these techniques?  Which of these do you believe would be the most difficult for you?  We will have a chance to practice these in our webinars, so keep them in mind.

Katherine Frey replied on

The GCN used all the basic interaction strategies in her conversation. She also did a brief summary after each topic, diet and exercise, stating her expectations for next time, in addition to a general summary at the end, which included how she was updating his action plan.  For both topics she made suggestions and asked for feedback from the patient, allowing him to make decisions on what to do.  Throughout the conversation, the nurse provided affirmation for his attempts, his care for his wife and how his actions were helping him advance toward his goal of "good health". 

Lauryn Mitchell replied on

Yes - I hope you were able to pick out the use of each specific technique.  We'll be reviewing these techniques in detail in next week's webinar, so you'll get to see them used AND have a chance to practice!

Katherine Frey replied on

open ended questions: "how do you feel about...?"

validation: "i really appreciate (his values).."'

encouragement of utilization of tools acquired: encouraging pt to teach others what he know - - - advancing him in stages of self activation

MI talk: development of a step by step process - reviewing details of current goal/modifying as needed and providing "action plan"

Camille Kimball replied on

Yes, these are definitely some of the elements of MI.  She used a number of open-ended statements and affirmation/validation.  She also used reflection, repeating back significant statements, and summarizing statements to capitalize on his change talk.

We will have a chance to practice these techniques on Thursday - looking forward to speaking with you then!

Katherine Frey replied on

The GCN used open-ended questions regarding diet/exercise and his feelings about health and family.  Affirmation about his feelings for his wife and trying to exercise/watch salt intake, how feels about Meals on Wheels.  Reflecting on what he has tried, encouraging to take small steps with exercise and slowly increasing to prevent fatigue, ideas on reducing salt.  Summarizing what has been discussed, giving choices to improve diet/exercise, setting up action plan, discuss what pt thinks he can do, what goals he would like to meet, and setting up follow up.

Doreen Morgan replied on

Yes - good job identifying the elements of MI used in this interaction.  They can be tricky to implement, so we will have plenty of opportunities to practice during our webinar tomorrow.  Talk to you then!

Katherine Frey replied on

Mr. Jackson--I would like to summarize this phone call with you--may I do that today?  You told me that you are aware that it would  be healthier for you if you ate at home more often.  You have practiced with me what you will say to your wife about the health benefits of eating more meals at home.  What other things can we do to make the upcoming talk with you wife more successful?  In regards to an activity program you have said that you will make a goal that you will walk to the mailbox 3 days a week--that is a great goal to set.  Please let me know if there is anything I can do to help you reach this goal.  In 1 month I will call you to see how you are coming along with these 2 goals and I would appreciate hearing from you before then if you have any cares or concerns about your health. 

Susan Cain replied on

This is a terrific summary of the conversation, and you demonstrate beautifully how you can use change talk to create action!  Well done.

Katherine Frey replied on

The GNC started out using teach back technique related to low salt diet .

She also encouraged conversation with open ended questions frequently saying ,What do you think about that? or How are things going with that?

Also affirming his concerns , eg.  causing too much work for his wife

Reflecting on his answers by saying ,It sounds like...

In the end she summarized the action plan and goals to be worked on prior to the next agreed upon date.

Cheryl Laneve replied on

Nice job identifying how the GCN used the MI OARS in this interaction.  I hope you'll take advantage of our opportunity to practice at tomorrow night's webinar.  Talk to you then!

Katherine Frey replied on

The Guided Care Nurse follows the guidelines of motivational interviewing by understanding, accepting, and validating.  She begins by restating his goal of eating less salt.  She asks how that is going, and is able to draw out the patient's progress and the reasoning behind it.  She uses optimism and understanding when she comments on how thoughtful he is about thinking of his wife.  She allows the patient to state the importance of using less salt in his diet, and then she validates his understanding.  She provides two healthy ideas, and then she gives him the option of talking to his wife about cooking more at home or utilizing meals on wheels.  When she reviews his progress on his exercise plan, she states what she understood to be his PT plan, and then asked how his plan had gone.  After he explained how he had approached his exercise plan and then had not gone further, the GC Nurse again used optimism, giving the patient credit for giving 110%,  and the understanding that he was motivated by wanting to spend time doing things with his wife.  She provided accurate information about exercise and how small steps would help him reach his goals.  Then she allowed the patient to set goals that he felt he could accomplish.  She noted that she would restate these goals on his action plan.  She ended both "talks" about salt and exercise with the statement that they would review the results of the plans at their next meeting.        

Shelly Wells replied on

Yes, you correctly identified all the elements of OARS used in this interaction. I hope it was helpful in demonstrating how we work with patients to use their goals as the motivation to make a change.

Katherine Frey replied on

The nurse played an effective role using the elements of guided care. Throughout the discussion she often asked open-ended questions to allow the patient to elicit expansive answers rather than simple yes/no responses. This also engages the patient and continues to helps to build the relationship between caregiver and patient. She asked "how are things going" or have you talked about..." and what do you think"? In the affirmative piece she repeated back what the pateint stated to validate his responses. She then used reflective listening to mirror back what the patient noted and allow for additional clarity. Reflective listening here also alowed her to utilize his statement about exercise and being tired, in turn as a motivator to exercise to reduce fatigue. Finally in summarizing the content of the discussion the patient and nurse can review key concepts and develop a plan looking forward, even if the changes are small.  Thanks Dawn

dawn sagliani replied on

Reply to this thread with your SBAR example from Course 4.

Katherine Frey replied on

If by phone, would introduce myself e.g. this is Sarah.  If in person, as the scenario appeared to be suggesting, would delete that piece since the assumption is Dr. Jones and Sarah work together.

S - Hi, Dr. Jones, this is Sarah.  I wanted to talk with you about Jeanne Paley.  She has been experiencing sharp, deep, constant abdominal pain for the past 2 days, stating a “9-10” in severity, has described “swollen lumps down there”and threw up twice today, small amount of watery liquid.

B – Mrs. Paley has had the swollen lumps and the pain for the past few weeks, described as in her stomach, abdomen and radiating to her lower back.  Initially she thought it was her hip acting up.  She thought she was constipated, took a Dulcolax, and has taken Gas-X, Tylenol, and Ibuprofen.  These have not helped reduce the pain.  She has not had diarrhea, does not believe she has a fever and has lost 5 lbs.

A –I’m concerned about the swollen lumps and the severity of the abdominal pain.

R – I believe she should be seen in your office today and I noted you have a free period between 1:30 and 2:00 p.m.  I told her I would call her back within the hour.  She believes her landlord can give her a ride to the office.  I’ve instructed her to take sips of water to stay hydrated until I call her back.

Patricia Watson-Wood replied on

This is a perfect example of the use of SBAR.  I like that you used words like "concerned," and that you were an advocate for her in making your recommendation.

Katherine Frey replied on

S: Dr. So-and so, I spoke with your pt Jeanne Paley today who c/o constant, sharp, "deep," low abd pain 9-10/10 diffuse to her low back x2 days with no relief since midnight and small watery emesis x2 this AM.

B: Prior to this she had been experiencing intermittent pain x a few weeks. Increasingly poor appetite with a 5lb wt loss. She also reports "swollen lumps down there" x a few mos. and is in remission for lymphoma x1 yr. She has taken dulcolax and Gas-X as well as ibuprofen and Tylenol for which she routinely takes for chronic pain in her R hip.

A: She denies fevers, any recent infections, or n/v before today. 

R: I've encouraged her to take sips of water for now. I'm concerned that her pain has become unmanageable and she should be seen today if possible.

Brandy Hinrichs replied on