Guided Tour

Chad Boult explains one way to make health care cheaper and better.

Lost during the months of intense, acrimonious debate about U.S. health care reform were common-ground priorities such as effective strategies that reduce costs. One such approach is Guided Care, a model of comprehensive, coordinated care for patients with multiple chronic conditions. In Guided Care, a registered nurse works in a primary care practice to coordinate care, engage patients and their family caregivers in self-management, and smooth transitions from hospital to home.The model was developed by Chad Boult, director of the Roger C. Lipitz Center for Integrated Health Care, and colleagues from Hopkins' Medicine and Nursing schools. Using preliminary data from Guided Care's three-year, randomized-controlled trial (which ended in June), Boult estimates the approach could save Medicare up to $15 billion per year while providing better care.The trial was funded by a public-private partnership of the Agency for Healthcare Research and Quality, the National Institute on Aging, the John A. Hartford Foundation and the Jacob and Valeria Langeloth Foundation.With the stoic patience of a veteran health policy expert, Boult doesn't expect Guided Care to be adopted immediately, though it has attracted interest from Congress and the Centers for Medicare & Medicaid Services. He hopes to nudge it into larger national trials soon. Boult recently shared his thoughts on the challenges and the future of chronic care with Johns Hopkins Public Health editor Brian W. Simpson.

As an expert in health and aging, how do you perceive the U.S. health care system?

Our system is designed to serve people who are basically healthy and then, once in a while, get sick or injured. But when people have five or six chronic diseases that are never going to go away and they all require care and medicines and visits to doctors, our system really doesn't serve them very well.

Give us an example of how the system fails.

The example that I sometimes use is a hypothetical patient who has five chronic conditions that she's never going to get rid of. In a typical year, two or three of those conditions might flare up, requiring visits to the emergency department and the hospital. These conditions might be diabetes or hypertension, or maybe heart disease or depression. She gets some acute care in the hospital and rehabilitation afterward and then goes back home again and is perhaps seen in the following months by maybe a psychiatrist for the depression and an endocrinologist for diabetes. There's also a primary care doctor involved, but the doctors aren't communicating with each other. As a result, sometimes what one very well-meaning specialist might do might have an adverse effect on a different condition.

Patients like this are obviously older, frail and likely to be hospitalized. How can a Guided Care nurse actually make a difference?

Several ways. One of the first things the nurse does for a new patient is to go out to the home and do a comprehensive assessment. This includes learning all about their medical conditions and medications, but also the safety of where they live, whether their appliances work, what's their nutritional status. The nurse looks in the refrigerator and the cupboards to see what the person's really eating and assesses whether the person's really able to take their medicines or not.

Out of that comes a detailed plan for managing this patient's conditions that includes both what the patient and the family are supposed to do, as well as the doctor and nurse. The nurse then monitors the patient every month, usually by phone. They'll go over all the medicines and all the dietary restrictions and all the physical activity that the person's doing and any necessary behavior change such as reducing salt or stopping smoking. The nurse also uses this opportunity to detect any deteriorating conditions.

One of the ways that this works is by detecting problems early and treating them before the patient needs to be hospitalized. Nip it in the bud is the idea there. But let's say the person does have a heart attack and needs to go into the hospital. The nurse works with the patient right through the hospital stay and makes sure that whatever was designed for the patient while she was in the hospital actually gets carried out after the patient goes home. A lot of times when the patient first goes home there can be a lot of confusion: Am I supposed to take all the old medicines plus all the new medicines? Or stop the old ones and start the new ones? Or what?

Tell us about your most recent study results.

We've been conducting a randomized trial for the last three years. It was conducted in eight sites in the Baltimore/Washington, D.C., area. It involved just over 900 older patients with multiple chronic conditions and 50 primary care doctors. Half of the patients received Guided Care, and the other half received the continuation of their usual care. Our study showed that Guided Care saves more money than it costs. The patients who enrolled in Guided Care were less likely to be admitted to the hospital and to visit the emergency room and have home care and visits to rehab. With all the expenses of having a nurse, there was still an average 11 percent reduction in the overall cost for the patient. To say that another way, each nurse saved about $75,000 for the system per year.

Wow.

I should point out that these results are preliminary. [They are] only the first year of the study and they didn't reach statistical significance, but they were in a direction that was encouraging.

You've said that Guided Care could save Medicare $15 billion a year. What would it take to realize that savings?

The idea of disseminating this model so that it becomes the standard of care in the country, I think, is really what we're talking about. First of all, it takes a payment source. Recall that the savings that I mentioned accrued to the health insurer, for example, Medicare. But the costs are accrued by the practice that has to hire the nurse. So there has to be a payment model by which the insurer pays the primary care practice to hire the nurse. That's what it takes to get this off the ground because practices, frankly, are not going to spend on average $96,000 a year for a Guided Care nurse without having some way to recover that cost. Then, of course, there is the issue of supply. Are there enough nurses? There are probably 500,000 nurses in this country who have current licenses but are not in the workforce, and we think that many of those might come out of their early or semi-retirement for a job like this. In the randomized trial we asked our nurses how they liked this job. They say, "This is what I went into nursing for in the first place, the opportunity to make a difference in people's lives, to get to know them over time, to help them in a real time of need."

Recently you were named a Health and Aging Policy Fellow and will spend a year in Washington, D.C. Are you excited to get into the policymaking side of things?

Yeah, I'm fascinated. Those of us who are not in the government don't really know what goes on inside the government. I call it the black box. We can give our advice and then we go away, and then they come out with a law. You never really know how effective you were in terms of giving them helpful information. So I'm really intrigued to live inside the black box for a year and really see how it works.