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Health care for older Americans with chronic conditions is often fragmented and provider-centric. In response, a team of investigators at Johns Hopkins University has translated the scientific principles of seven successful innovations into one patient-centered system of care.

A specially trained Guided Care Nurse (GCN), based in a primary care practice, collaborates with two primary care physicians to provide services for 40-60 high-risk patients.

 

Services Provided through Guided Care:

• Assessing the patient and primary caregiver at home
• Creating an evidence-based “Care Guide” and “Action Plan
• Promoting patient self-management
• Monitoring the patient’s conditions monthly
• Coordinating the efforts of all the patient’s health care providers
• Smoothing the patient’s transitions between sites and providers of care
• Educating and supporting unpaid (family) caregivers
• Facilitating access to community resources

 

 

For more information on Guided Care, please visit the Johns Hopkins website.