Site Visit

Coordinating Care for People with Multiple Chronic Conditions: The Guided Care Model and Other Innovative Approaches
April 17 & August 7, 2009


Judith D. Moore & Carol V. O'Shaughnessy, MA


The Forum sponsored two site visits to explore the Johns Hopkins University's research and demonstration program on Guided Care, in April and August 2009. Guided Care is a patient-centered medical home model that uses an interdisciplinary approach to coordinating health care for older people with multiple chronic conditions. Guided Care nurses located in primary care practices work with Medicare patients on a long-term basis, coordinate their care among various providers, provide transitional care, and assist patients with self-management skills. Site visit participants learned about the complexities of caring for frail Medicare patients, some of whom see multiple physicians and other health care providers on a continuous basis. Guided Care nurses, physicians, and patients discussed with the site visit participants the impact of the program on medical practice and individual patients and the research results of the Guided Care approach on cost and quality outcomes.

Related Materials

For a summary of the site visits, see the Site Visit Report, published September 30, 2009.

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