Guided Care is a model of proactive, comprehensive health care for people with several chronic conditions. A form of medical home, the model has been developed and tested by a multidisciplinary team of experts at the Roger C. Lipitz Center for Integrated Health Care[1] in the Johns Hopkins Bloomberg School of Public Health. Guided Care is provided by physician-nurse teams in primary care practices to the physicians' most complex patients, mainly older adults with chronic conditions and complicated health needs. It is designed to increase patients' quality of care and quality of life, while improving the efficiency of their use of health care resources, thus reducing their overall health care costs.
In Guided Care, a registered nurse based in a primary care office works closely with three to four physicians to provide state-of-the-art chronic care for 50–60 chronically ill patients. Following a comprehensive assessment and an evidence-based care planning process, the Guided Care nurse monitors patients, promotes self-management, smooths transitions between sites of care, educates and supports family caregivers, facilitates access to community resources, and coordinates the efforts of health care professionals, hospitals and community agencies to avoid duplication and conflicting advice. The goal is to ensure that no important health-related needs are overlooked.[2]