Johns Hopkins Care Model Slashes Costs, Raises Quality and Satisfaction
by Maggie Van Dyke
The Johns Hopkins Guided Care model works—from a quality
and a cost perspective. The intensive case management approach
for older patients with multiple chronic conditions improves the
quality of health care and appears to reduce hospitalizations,
ED visits, and other expensive medical services. The model is
lauded as a type of medical home that is relatively simple to
implement. Most important: Everyone involved—patients, family
caregivers, nurses, physicians—enthusiastically applauds Guided
Care.
Why isn’t this care approach being offered more widely? The
missing link is a payment source.
Getting physicians to adopt Guided Care
Guided care pilot demonstrates positive outcomes
Getting insurers to fund Guided Care
A simplified medical home model
Reducing the cost of complex care
Sidebar: What exactly is Guided Care
Getting Physicians to Adopt Guided Care
When Johns Hopkins researcher Chad Boult, MD,
MPH, MBA, first approached primary care
physicians with his idea to offer intensive case
management to their high-risk patients, they
were skeptical.
Boult offered to provide seven physician
practices with a free RN—paid for by research
funds—to work in the practice providing
one-on-one care for 50 to 60 of their most
complicated older patients, typically those with
four to five chronic conditions. The nurses
would visit and frequently call the patients and
work with the physicians on plans to manage
their chronic conditions and prevent potential
health problems (see the sidebar for more about
the Guided Care model).
“Physicians are stretched so thinly these days.
They were worried that this was going to be one
more thing for them to do,” says Boult.
Three years later, all the physicians who
participated in the clinical trial lamented the
study’s end. “They completely turned around,”
says Boult. “One of the physicians told me, ‘I
used to be embarrassed by the care we were
giving to these older patients. I only had 15
minutes to see them, and it took the patient
that long to get in the exam room, get up on the
table, and tell me their most important concern.
Then I’d refill their medications and send them
out the door. And I had ignored their six other
problems.”
Now this same physician is proud of the care
he’s providing. “These patients really need our
help and now, with the nurse’s assistance, I can
give care that I’m proud of.”
Pilot Demonstrates Positive Outcomes
Results from the Guided Care randomized trial
show that the model improved patients’ quality
of care, reduced family caregiver strain, and
produced high job satisfaction among
participating nurses and physicians.
The model also appeared to reduce medical costs,
resulting in an annual $1,364 savings per
patient. Compared to patients who received usual
care, Guided Care patients experienced, on
average, 24 percent fewer hospital days, 37
percent fewer skilled nursing facility days, 15
percent fewer ED visits, and 29 percent fewer
home health care episodes. (Leff, B., et al.,
“Guided Care and the Cost of Complex Healthcare:
A Preliminary Report,” The American Journal
of Managed Care, vol. 15, no. 8, pp.
555-559.)
“Guided Care patients cost health insurers 11
percent less than patients in the control
group,” says Boult. “If you apply that rate of
savings to the 11 million eligible Medicare
beneficiaries, programs like Guided Care could
potentially save Medicare more than $15 billion
every year.”
Getting Insurers to Fund Guided Care
The Guided Care program costs a physician
practice about $96,000 per nurse per year, says
Boult. That covers the nurses’ salary and
benefits, as well as the nurse’s computer, cell
phone, and travel expenses.
“Of course, that’s a substantial amount of
money, and most physician practices aren’t able
to allocate that money from their budget. And
there is no way a practice can generate extra
billings of that magnitude to offset the cost of
the nurse.”
The funding for the Guided Care study, which was
provided by the Agency for Healthcare Research
and Quality, the National Institute on Aging,
and the John A. Hartford Foundation, ended
earlier this year. Fortunately, six of the seven
physician practices continue to provide Guided
Care to patients—after insurers recognized that
it was in their interest to assume the cost of
the program.
“Insurers are wise to pay physician practices a
monthly fee to give high-risk patients Guided
Care,” says Boult. “The insurer is the party
that benefits from reductions in hospitalization
and other medical costs. Even after you account
for the cost of the nurse, Guided Care still
resulted in a net savings of about $75,000 per
nurse per year.”
Realistically, Boult recognizes that his Guided
Care model is not feasible for practices that
rely heavily on fee-for-service payments because
they don’t cover the nurse’s services. In fact,
one of the Guided Care physician practices—which
was entirely fee-for-service Medicare
patients—had to end their Guided Care program
when the study ended.
The model stands a better chance of getting
funded by payers or providers—for example, in
fixed payment contracts—that stand to
financially benefit by preventing the use of
unnecessary medical services, says Boult.
The two insurers now paying for Guided Care are
both financially motivated to pay money upfront
to avoid costs downstream, says Boult. One is
Kaiser Permanente, a health plan that operates
its own physician practices. The other insurer
is TriCare, a military insurance program.
A Simplified Medical Home Model
The Guided Care model has something else on its
side: The relative simplicity of adopting it.
“I refer to Guided Care as a type of medical
home,” says Boult. “Guided Care is like a
medical home in that the physician-nurse team
provides comprehensive, coordinated care to
patients, the patients get involved in their own
care, and the nurse tracks everything that
happens to the patient.”
What’s different from a typical medical home
model? Guided Care only focuses on high-risk
patients, or the riskiest 25 percent of patients
with chronic conditions. And the case management
provided is very intense, with a lot of
one-on-one face time between the nurse and the
patient.
A typical medical home provides less intensive
patient management—but for all the patients in
the practice. Medical homes often track patients
with chronic conditions via “registries” and use
disease management techniques to improve the
health of these patients.
“To implement a typical medical home, you really
have to transform the whole practice and how
everything gets done,” says Boult. “It could
take years to put such a comprehensive type of
medical home in place.”
In contrast, the Guided Care is fairly easy to
implement, says Boult. “You hire a nurse, put
her through the Guided Care training program,
integrate her into the practice, and you’re
running.” (Note: The Institute of John Hopkins
Nursing currently offers a Guided Care nurse
certification program.)
Reducing the Cost of Complex Care
The Guided Care model is the only type of
medical home to have been studied in a
randomized control trial—and shown to save costs
while controlling quality.
However, this doesn’t mean it’s for everyone.
Guided Care is designed for older patients with
several chronic diseases. A minority of patients
need such intensive oversight. And the cost of
providing such intensive case management to all
patients would be prohibitive.
A typical disease management approach works well
for patients with one or two chronic problems,
says Boult. “It tends to get more cumbersome
when a patient has five or six chronic problems.
For instance, you may notice a patient’s
diabetes is out of control, but if you only
focus on that and ignore his five other
problems, then you won’t necessarily reduce his
risk of hospitalization.”
“To be cost effective, a model like Guided Care
has to focus on the high-cost people,” he says.
“And the way to reduce medical costs for these
patients is to give them intensive care with a
nurse who really knows them and works one-on-one
with them.”
Learn more at the
Guided Care
web site.
Interviewed for this article: Chad Boult, MD,
MPH, MBA, the Eugene and Mildred Lipitz
professor of Health Policy and Management at the
Johns Hopkins Bloomberg School of Public Health,
and director of the Roger C. Lipitz Center for
Integrated Health Care.
Maggie Van Dyke is the editor of the
Leadership publications (mvandyke@hfma.org).
Sidebar
What Exactly Is Guided Care?
Guided Care
is a model of proactive, comprehensive health care provided by
physician-nurse teams for people with several chronic health conditions. It
can provide a medical home for the growing number of older adults with
chronic health conditions. This model is designed to improve patients'
quality of life and care, while improving the efficiency of treating the
sickest and most complex patients. The care teams include a registered
nurse, two to five physicians, and other members of the office staff who
work together for the benefit of each patient to
? Perform a comprehensive assessment at home
? Create an evidence-based care guide and action plan
? Monitor and coach the patient monthly
? Coordinate the efforts of all the patient's healthcare
providers
? Smooth the patient's transition between sites of care
? Promote patient self-management
? Educate and support family caregivers
? Facilitate access to appropriate community resources