Johns Hopkins Bloomberg School of Public Health

jessievenegas Jessie Venegas — 12/01/2009


Specially trained nurses work with primary care physicians (PCPs) in their offices to improve care for seniors with multiple chronic illnesses by coordinating care, facilitating transitions in care, and acting as the patient’s advocate across health care and social settings. Nurses use an electronic health record (EHR) and a variety of established methods, including disease management, case management, transitional care, self-management, lifestyle modification, caregiver education and support, and geriatric evaluation and management. A pilot study found that the program, known as "Guided Care," improved patient perceptions of the quality of their care. In addition, over a 6-month period, Guided Care reduced hospital and emergency department (ED) admissions and hospital days, resulting in 23-percent lower expenses than patients who received usual care (as measured by third-party insurance records).

Fragilidad, pluripatología o polipatología y/o enfermedades crónicas complejas






Baltimore, MD 21205
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