Katherine Frey

The Effects of Guided Care on the Perceived Quality of Health Care for Multi-morbid Older Persons: 18-Month Outcomes from a Cluster-Randomized Controlled Trial

BACKGROUNDThe quality of health care for older Americans with chronic conditions is suboptimal.OBJECTIVETo evaluate the effects of “Guided Care” on patient-reported quality of chronic illness care.DESIGNCluster-randomized controlled trial of Guided Care in 14 primary care teams.PARTICIPANTSOlder patients of these teams were eligible to participate if, based on analysis of their recent insurance claims, they were at risk for incurring high health-care costs during the coming year. Small teams of physicians and their at-risk older patients were randomized to receive either Guided Care (GC) or usual care (UC).INTERVENTION“Guided Care” is designed to enhance the quality of health care by integrating a registered nurse, trained in chronic care, into a primary care practice to work with 2–5 physicians in providing comprehensive chronic care to 50–60 multi-morbid older patients.MEASUREMENTSEighteen months after baseline, interviewers blinded to group assignment administered the Patient Assessment of Chronic Illness Care (PACIC) survey by telephone. Logistic and linear regression was used to evaluate the effect of the intervention on patient-reported quality of chronic illness care.RESULTSOf the 13,534 older patients screened, 2,391 (17.7%) were eligible to participate in the study, of which 904 (37.8%) gave informed consent and were cluster-randomized. After 18 months, 95.3% and 92.2% of the GC and UC recipients who remained alive and eligible completed interviews. Compared to UC recipients, GC recipients had twice greater odds of rating their chronic care highly (aOR = 2.13, 95% CI = 1.30–3.50, p = 0.003).CONCLUSIONGuided Care improves self-reported quality of chronic health care for multi-morbid older persons.

Physician Satisfaction with Chronic Care Processes: A Cluster-Randomized Trial of Guided Care

PURPOSE Chronically ill older patients with multiple conditions are challenging to care for, and new models of care for this population are needed. This study evaluates the effect of the Guided Care model on primary care physicians’ impressions of processes of care for chronically ill older patients. METHODS In Guided Care a specially educated registered nurse works at the practice with 2 to 5 primary care physicians, performing 8 clinical activities for 50 to 60 chronically ill older patients. The care model was tested in a cluster-randomized controlled trial between 2006 and 2009. All eligible primary care physicians in 14 pods (teams of physicians and their chronically ill older patients) agreed to participate (n = 49). Pods were randomly assigned to provide either Guided Care or usual care. Physicians were surveyed at baseline and 1 year later. We assessed the effects of Guided Care using responses from 38 physicians who completed both survey questionnaires. We measured physicians’ satisfaction with chronic care processes, time spent on chronic care, knowledge of their chronically ill older patients, and care coordination provided by physicians and office staff. RESULTS Compared with the physicians in the control group, those in the Guided Care group rated their satisfaction with patient/family communication and their knowledge of the clinical characteristics of their chronically ill older patients significantly higher (ρ<0.05 in linear regression models). Other differences did not reach statistical significance. CONCLUSIONS Based on physician report, Guided Care provides important benefits to physicians by improving communication with chronically ill older patients and their families and in physicians’ knowledge of their patients’ clinical conditions.

Guided care: a new frontier for adults with chronic conditions

Purpose This article describes “Guided Care,” a promising new model of case management that includes disease management, self-management, transitional care, and caregiver support for multimorbid patients and their families. Primary Practice Settings Guided Care nurses, based at primary care practices, extend services to the home and all the other settings where their patients receive care. Findings and Conclusions Guided Care nurses take responsibility for 50—60 multimorbid patients. For each patient, the nurse performs a home assessment and creates an evidence-based plan of care. In partnership with the primary physician, the Guided Care nurse then monitors and coaches the patient monthly, coordinates the patients transitions between providers and sites of care, educates and supports family caregivers, and facilitates access to community resources. Implications for Case Management Practice As a next stage in the evolution of case management, Guided Care may be supported by Medicare and, therefore, adopted widely throughout the American healthcare.

Building a clinical research network in trauma orthopaedics: The major extremity trauma research consortium (METRC)

Objectives: Lessons learned from battle have been fundamental to advancing the care of injuries that occur in civilian life. Equally important is the need to further refine these advances in civilian practice, so they are available during future conflicts. The Major Extremity Trauma Research Consortium (METRC) was established to address these needs. Methods: METRC is a network of 22 core level I civilian trauma centers and 4 core military treatment centers—with the ability to expand patient recruitment to more than 30 additional satellite trauma centers for the purpose of conducting multicenter research studies relevant to the treatment and outcomes of orthopaedic trauma sustained in the military. Early measures of success of the Consortium pertain to building of an infrastructure to support the network, managing the regulatory process, and enrolling and following patients in multiple studies. Results: METRC has been successful in maintaining the engagement of several leading, high volume, level I trauma centers that form the core of METRC; together they operatively manage 15,432 major fractures annually. METRC is currently funded to conduct 18 prospective studies that address 6 priority areas. The design and implementation of these studies are managed through a single coordinating center. As of December 1, 2015, a total of 4560 participants have been enrolled. Conclusions: Success of METRC to date confirms the potential for civilian and military trauma centers to collaborate on critical research issues and leverage the strength that comes from engaging patients and providers from across multiple centers.

Who participates in chronic disease self-management (CDSM) programs? Differences between participants and nonparticipants in a population of multimorbid older adults.

Background:Self-care management is recognized as a key component of care for multimorbid older adults; however, the characteristics of those most likely to participate in Chronic Disease Self-Management (CDSM) programs and strategies to maximize participation in such programs are unknown. Objectives:To identify individual factors associated with attending CDSM programs in a sample of multimorbid older adults. Research Design:Participants in the intervention arm of a matched-pair cluster-randomized controlled trial of the Guided Care model were invited to attend a 6-session CDSM course. Logistic regression was used to identify factors independently associated with attendance. Subjects:All subjects (N=241) were aged 65 years or older, were at high risk for health care utilization, and were not homebound. Measures:Baseline information on demographics, health status, health activities, and quality of care was available for CDSM participants and nonparticipants. Participation was defined as attendance at 5 or more CDSM sessions. Results:A total of 22.8% of multimorbid older adults who were invited to CDSM courses participated in 5 or more sessions. Having better physical health (odds ratio [95% confidence interval]=2.3 [1.1–4.8]) and rating one’s physician poorly on support for patient activation (odds ratio [95% confidence interval]=2.8 [1.3–6.0]) were independently associated with attendance. Conclusions:Multimorbid older adults who are in better physical health and who are dissatisfied with their physicians’ support for patient activation are more likely to participate in CDSM courses.

Improving pain management and long-term outcomes following high-energy orthopaedic trauma (pain study)

Poor pain control after orthopaedic trauma is a predictor of physical disability and numerous negative long-term outcomes. Despite increased awareness of the negative consequences of poorly controlled pain, analgesic therapy among hospitalized patients after orthopaedic trauma remains inconsistent and often inadequate. The Pain study is a 3 armed, prospective, double-blind, multicenter randomized trial designed to evaluate the effect of standard pain management versus standard pain management plus perioperative nonsteroidal anti-inflammatory drugs or pregabalin in patients of ages 18-85 with extremity fractures. The primary outcomes are chronic pain, opioid utilization during the 48 hours after definitive fixation and surgery for nonunion in the year after fixation. Secondary outcomes include preoperative and postoperative pain intensity, adverse events and complications, physical function, depression, and post-traumatic stress disorder. One year treatment costs are also compared between the groups.

The Trauma Collaborative Care Study (TCCS)

Previous research suggests that the care provided to trauma patients could be improved by including early screening and management of emotional distress and psychological comorbidity. The Trauma Collaborative Care (TCC) program, which is based on the principles of well-established models of collaborative care, was designed to address this gap in trauma center care. This article describes the TCC program and the design of a multicenter study to evaluate its effectiveness for improving patient outcomes after major, high-energy orthopaedic trauma at level 1 trauma centers. The TCC program was evaluated by comparing outcomes of patients treated at 6 intervention sites (n = 481) with 6 trauma centers where care was delivered as usual (control sites, n = 419). Compared with standard treatment alone, it is hypothesized that access to the TCC program plus standard treatment will result in lower rates of poor patient-reported function, depression, and posttraumatic stress disorder.