Guided Care Patient-Centered Medical Home

Improving Chronic Illness Care
August 7, 2019
Collaborative Management of Chronic Illness. Archives of Internal Medicine
August 7, 2019

Guided Care Patient-Centered Medical Home

Guided Care® provides many aspects of a “patient-centered medical home” for the growing number of older adults with complex health needs. Scientific studies have shown that Guided Care improves the quality of care and suggests that it reduces overall health care costs. In Guided Care, a registered nurse, who is based in a primary care office, works closely with 3-4 physicians and health information technology to provide state-of-the-art care for 50-60 chronically ill Medicare beneficiaries. Following a comprehensive assessment and planning process, the Guided Care nurse educates and empowers patients and families, monitors their conditions monthly, and coordinates the efforts of health care professionals, hospitals and community agencies to be sure that no important health-related need slips through the cracks

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