THE PROBLEM: Providing high-value care for older adults with chronic conditions and complex care needs is becoming increasingly important as the fragmented, reactive U.S. healthcare system attempts to care for the rapidly expanding population of older Americans. 

THE SOLUTION: In Guided Care, a registered nurse partners with a primary care practice's providers in delivering coordinated, proactive care to their chronically ill patients. The Guided Care® team consists of a Guided Care nurse (GCN), based in a primary care practice, working with 2 to 5 physicians and other care team members to provide coordinated, patient-centered, cost-effective health care to 75 to 100 of their chronically ill patients. Guided Care RNs are trained to coordinate care, monitor patients, and teach patients and families self-management skills, including early identification of worsening symptoms that can be addressed before an emergency department visit or hospital admission becomes necessary. GCNs typically focus on Medicare beneficiaries in the top quartile of health risk.

Unlike most care/case managers, Guided Care Nurses are highly trained, based on primary care practices, monitor their patients long-term, provide intensive transitional care, and use motivational interviewing to help patients manage their chronic conditions. Guided Care Nurses also provide continuing education, resources, and support for their patients' family caregivers.

OUTCOMES: In the growing number of practices that are funded by value-based payment plans, Guided Care:

• Improves the quality of patient care
• Improves family caregivers’ perception of quality of care
• Produces high job satisfaction among Guided Care nurses
• Improves physicians’ satisfaction with chronic care
• Reduces the use of expensive services

CERTIFICATE: This course is the only approved training to become a Guided Care Nurse. Nurses who complete this course will receive a certificate of completion in Guided Care Nursing from Johns Hopkins. Learn more about Guided Care Nursing.