Guided Care Nursing | A Team Approach to the Care of Chronically Ill Older Patients

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.

Course summary
Available credit: 
  • 15.00 ANCC
  • 15.00 Attendance
Registration opens: 
Registration closes: 
  • Accreditation Statement: The Institute for Johns Hopkins Nursing is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.
  • Statement of Contact Hours:  This 15-contact-hour educational activity is provided by The Institute for Johns Hopkins Nursing. The 15 contact hours will be awarded after the completion of the course and the submission of the final course evaluation.
  • Conflict of Interest:  It is the policy of The Institute for Johns Hopkins Nursing to require our continuing nursing education program faculty and planning committee members to disclose any financial relationships with companies providing program funding or manufacturers of any commercial products discussed in the program.  The planning committee and program faculty report that they do not have financial relationships with manufacturers of any commercial products they discuss in the program.
  • Commercial Support:  This educational activity has not received any form of commercial support.
  • Non-Endorsement of Products:  The Institute for Johns Hopkins Nursing and the American Nurses Credentialing Center do not endorse the use of any commercial products discussed or displayed in conjunction with this educational activity.

Available Credit

  • 15.00 ANCC
  • 15.00 Attendance


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