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Guided Care

jessievenegas Jessie Venegas — 11/01/2009

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).

Fragility, pluripathology/polipathology and/or complex chronic diseases

Goals Prevention:
Funding for detection programs , Promotes adecuate understanding levels on the community about the importance of prevention
Goals Detection:
Promotes early intervention through primary health care measures , Provides registries and patients contact systems , Shows new evidence on the importance of early detection, including guidelines of effective practices
Goals Treatment:
Develop basic elements for an integrated health system , Provides support health policies to facilitate the planning and integration at locally and regionally , Strengthens cooperative local groups to provide integral services , Improving access to health services across the entire spectrum, from prevention to treatment , Ensures the best quality of health services , It facilitates the management by processes , Emphasizes the care of pluri-pathological and fragile patients , Promotes electronic health information systems to improve the quality of care
Goals self-management:
Refocuses the health system to support self-management , Promotes patient involvement in planning services , Improving support services with an emphasis on peer support, the disabled and carers , Allows remote support to patients and their carers from health professionals








624 N. Broadway, Room 693

MD 21205
Practices Map



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