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scientific computing an introductory survey solutions manualOUR MISSION Guided HealthCARE, a Nursing corporation MEET OUR TEAM OUR SERVICES GHC acts as a liaison Guided Health CARE is an invaluable asset to our family; they have significantly enhanced the quality of life for our parents and for us, their family care givers.” She is a graduate of St. Joseph Hospital School of Nursing and Millersville University in Pennsylvania. MESSAGE FROM OUR FOUNDER For nearly 25 years as a Critical Care Nurse, I have helped patients, their families and loved ones, in the acute care environment and in the community, to navigate challenging medical conditions. My goal is for Guided HealthCARE to be the best possible resource for providing comprehensive clinical based Nurse Care Coordination and Case Management. The need for skilled Nurses to work effectively and efficiently with the clinical team to provide comprehensive support and education for patients and families has increased. In addition to the clinical support, expertise is needed to help assemble resources required for stabilization outside the hospital. They rely upon Guided HealthCARE to provide the level of care and support they want for their loved ones. We often work with our patients and families for a long period of time, through many chapters in their life cycle. Given this relationship, the information we are able to share with the medical team creates a universal awareness, continuity of care and better outcomes overall. Laura earned her degree in Nursing at St. Joseph Hospital School of Nursing and Millersville University in Lancaster, Pennsylvania. She brings an additional 17 years of business experience in the marketing, advertising and entertainment industries and over twenty years of Neuro-Trauma, Coronary Care and Medical-Surgical Intensive Care Nursing to Guided HealthCARE. Laura transitioned her work from the Critical Care setting to the community to support chronically ill patients, families and the medical team as they navigate the healthcare system.http://www.hk-keber.de/images/brondi-fx-600-manual.xml
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Joni Campbell, RN PHN MSN Joni Campbell, RN PHN MSN Practice Manager Joni is a Registered Nurse with 20 years of experience in Cancer Research Project Management at the University of California at San Francisco. She received her Bachelor of Science in Physiology then her Master of Science in Nursing at San Francisco State University and is also a Certified Public Health Nurse. Joni brings high level Nurse Management and patient support to Guided HealthCARE in her role as Practice Manager. Sharon Baldoza, RN BSN CLNC Sharon Baldoza, RN BSN CLNC Clinical Nurse Case Manager Sharon is a Registered Nurse with over 25 years of experience. She received her Bachelor of Science in Nursing from San Francisco State University and is Certified as a Legal Nurse Consultant. Her nursing experience includes Acute, Sub Acute, Adult and Geriatric Nursing, Skilled Nursing, Residential Care for the Elderly, Outpatient Ambulatory Care Surgery, and Adult Home Health Nursing. Sharon’s experience as an LNC offers added benefit to our growing patient population supported by fiduciaries and conservatorships. She received her Bachelor of Science in Nursing from Arizona State University. She also obtained a Master’s in Business Administration with a focus in Healthcare Management from Western Governors University. Her experience includes Adult Neuro-Trauma, Cardiovascular and Medical-Surgical Intensive Care Nursing. She has transitioned to the community to focus on preventative care, to help patients navigate the healthcare system and to provide continuity of care from the acute care setting. Marie Ospeck, RN BSN MPA Marie Ospeck, RN BSN MPA Clinical Nurse Case Manager Marie is a Registered Nurse with over 25 years of experience. She received her Bachelor of Science in Nursing at St. She also has a Masters In Public Administration with a Concentration in Health Services Administration from the University of San Francisco.http://www.fiacasyfutones.com.ar/userfiles/dell-rev-a02-monitor-manual.xml Marie brings a broad scope of experience to her work with patients and families in navigating their complicated healthcare needs. Lindsay van der Bokke, RN BSN Lindsay van der Bokke, RN BSN Clinical Nurse Case Manager Lindsay van der Bokke, received her BSN degree from University of San Francisco and served as a Nurse for over 12 years at Stanford Healthcare, working in the IICU with heart, lung and kidney transplant patients. She found her passion as a Nurse Coordinator in the Stanford Cancer Center caring for both the patients and their families in the high risk and cancer community. Sujatha Vasudevan, RN MSN CHPN Sujatha Vasudevan, RN MSN CHPN Clinical Nurse Case Manager Sujatha is a Registered Nurse with 14 years of experience. She received her Bachelor of Music from the New England Conservatory of Music, and later received her Master of Science in Nursing in Healthcare Systems Leadership at the University of San Francisco in 2007, with a concentration in Case Management. Sujatha worked at San Francisco General Hospital for 10 years, with a focus on public health and working with the underserved. Christina Humm Christina Humm Controller Christina brings over 25 years of financial and accounting experience to Guided HealthCARE. She holds a Bachelor of Science in Business Administration and Accounting from San Diego State. Christina manages and oversees the company’s financial operations. Kelly St. Germain Kelly St. Germain Office Manager Kelly brings 25 years of experience in business development, strategic marketing, corporate finance and small business accounting to Guided HealthCARE. She holds dual Bachelor of Arts in Business Administration and Communications from the University of Pittsburgh. Kelly brings system wide support to our team in the role of Office Manager.https://www.airyachtnboat.com/en/article/how-uninstall-hips-mcafee-manually We are a clinically based practice, fully staffed with Registered Nurses, that supports chronically ill patients in the community, their loved ones, either local or distant, and their medical team. We assist our clients in navigating the health care system, coordinating all aspects of care and providing guidance to help patients and families make informed decisions to obtain the best health care options possible. For those committed, there is potential for growth into the role of Charge Nurse. 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. 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.Guided Care has received the 2009 Medical Economics Award for Innovation in Practice Improvement cosponsored by the Society of Teachers of Family Medicine, the American Academy of Family Physicians, and Medical Economics magazine.CS1 maint: archived copy as title ( link ) Retrieved 2009-10-12. CS1 maint: archived copy as title ( link ) CS1 maint: archived copy as title ( link ) By using this site, you agree to the Terms of Use and Privacy Policy. Our regulatory tested procedures and credentialed contract professionals make Guided Health a first choice for the risk-averse administrator. Call for more information: 503-260-0116 back to menu Vision To bridge Eastern and Western medicine within the contemporary medical environment.You are hiring quality professionals, and that your acupuncturists are credentialed. There is adequate peer review. Acupuncturists meet hospital standards of care. Appropriate documentation will be presented to inspectors.The Guided Health Model has been created to complement existing treatment modalities without interupting existing procedures. Learn More. PMCID: PMC3042340 PMID: 21369513 Improving Chronic Care: The “Guided Care” Model Chad Boult, MD, MPH, MBA, Lya Karm, MD, and Carol Groves, RN, MPA Author information Copyright and License information Disclaimer Chad Boult, MD, MPH, MBA, (top) is Director, Lipitz Center for Integrated Health Care, and Professor in the Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University; and a participant on the Advisory Panel of the Case Management Society of America's National Transitions of Care Coalition to improve the quality of care between health care settings. Introduction: What's the Problem. Everyone is working hard, but the quality of chronic care is still mediocre. Donald Berwick, MD, says “every system is designed perfectly to achieve the results that it achieves.” 1 The problem is the growing mismatch between the chronic care needs of the population and the acute care orientation of the health care system. Sixty-five million older people with multiple chronic conditions are trying to get health care from a system that is designed to treat acute illnesses and injuries. It's as though we are trying to put a square peg in a round hole. We will continue to get the poor results we are now getting until we redesign the system. Guided Care is a new model for “chronic care” that is now being tested by Kaiser Permanente (KP) in the Baltimore-Washington, DC area. Guided Care is primary health care infused with the operative principles of recent innovations to ensure optimal outcomes for patients with chronic conditions and complex health care needs. A Typical Case Ms Marian Chen is a 79-year-old widow who lives alone. She receives Social Security benefits and a modest pension; she is enrolled in a KP Medicare Health Plan. Her daughter lives ten miles away and is busy dealing with her three teenagers. Ms Chen has five chronic conditions for which she sees three physicians and takes eight prescription medications every day. The patient has had a very busy and medically complex year. She has seen eight physicians, five physical therapists, four occupational therapists, 37 nurses, and six social workers. This was the result of her chronic conditions flaring up and causing two hospitalizations, followed by inpatient postacute care and home care ( Figure 1 ). At each transition, a new team of clinicians assessed the patient and created a new care plan. The patient rates her quality of life as poor. Her daughter, to help, has reduced her workload to half-time, and is now considering nursing home options for her mother. She doesn't think she can keep doing this much longer. The family's experiences, which are not unusual, show that chronic care is:The Cost of Chronic Care Figure 2 shows the nation's Medicare expenditures for beneficiaries with different numbers of chronic conditions. Patients having four or more chronic conditions (about 25 of the older population) account for 80 of all Medicare spending. So chronic care stresses not only the patient, the patient's family, and the employer, but also the budgets of health care organizations and the federal government. Today there are about 65 million older Americans with multiple chronic conditions; by 2010 there will be 70 million. Unless changes are made, the magnitude of the chronic care problem will grow every year for the next three decades. The Chronic Care Model Wagner and Bodenheimer 3 have proposed the “Chronic Care” model for improving chronic care ( Figure 3 ). This model asserts that improving chronic care will require simultaneous improvements in support for self-management, design of practices, decision support, clinical information systems, and integration of community resources into health care. According to the model, improvements in these processes will foster more productive interactions between patients who are informed participants in their care, and practice teams that are prepared and proactive in providing care. Ultimately, these productive interactions should improve the outcomes of chronic care. Open in a separate window Figure 3 The Chronic Care model for improving outcomes. The Guided Care Model In designing Guided Care, we used the Chronic Care model to select several successful innovations in chronic care. We then combined these innovations to create the Guided Care model. During the past 20 years, pioneers have created innovations capable of improving several of the individual processes of chronic care. Kate Lorig, RN, DrPH, for example, has shown that her chronic disease self-management course can empower patients to become more informed and active in their own health care, resulting in improved quality of life and lower health care costs. 4 Similarly, Mary Naylor, RN, PhD, and Eric Coleman, MD, MPH, have developed approaches to transitional care that can reduce the need for readmission to hospitals. 5, 6 Others have conducted successful experiments with family caregivers, disease management, and case management. To create the Guided Care model, we combined the principles underlying such innovations and integrated them with primary care. We hypothesize that this approach improves the quality of care, patients' access to care, and their capacity for self care, thus resulting in improved health outcomes ( Figure 4 ). Our goal is to develop a model of care that is sustainable and diffusible throughout the health care system. Therefore, we also designed Guided Care to be:What Guided Care Looks Like in Practice Guided Care is driven by a highly skilled registered nurse in a primary care office. The Guided Care nurse assists three to four physicians in providing high-quality chronic care for their patients in need of good chronic care. Who is Eligible for Guided Care. Those eligible for Guided Care are high-risk patients with several chronic conditions and complex health care needs in a primary care practice. To select eligible patients, we use predictive modeling software to analyze patients' encounter data for the previous year. This “hierarchical condition category” (HCC) software a assigns points to each diagnosis from each encounter and computes a risk rating for each patient. The 25 of patients with the highest risk of needing complex health care in the coming year are eligible to receive Guided Care. Preparing the Guided Care Nurse Curricular Phase Critical to the success of Guided Care is the preparation of the Guided Care nurse. We have designed a case-based, three-week curriculum that teaches RNs the special skills they will need to practice Guided Care, including the use of the Guided Care electronic health record (EHR), transitional care, motivational interviewing, evidence-based guidelines for managing chronic conditions, health insurance coverage, and working with family caregivers and community agencies. The curriculum includes self-learning material and interactive workshops with instructors and other nurses. Integrative Phase Following the three-week curricular phase in the classroom, the nurse completes a four- to five-month integration into the primary care practice. To become an effective member of the practice, the nurse develops working relationships with the physicians, the other nurses, the support staff, and the receptionists, learning how each part of the practice functions. Guided Care Services For each patient, the Guided Care nurse provides eight services: 7 1. Assessing The nurse begins by performing a two-hour comprehensive assessment at the patient's home. This assessment covers medical conditions, medications, functional ability, mental status, exercise, nutrition, home safety, caregivers, other providers, and insurance. The nurse then reviews the patient's medical record and enters all the assessment data into the Guided Care EHR, which is separate from KP's “HealthConnect” electronic medical record. 2. Planning Care On the basis of this assessment data and recent evidence-based guidelines, which are programmed into the EHR, the EHR generates the patient's individualized Care Guide. This Care Guide is an integrated compilation of all the recommendations for managing the patient's chronic conditions. The nurse and the primary care physician discuss and modify the Care Guide to meet the patient's unique circumstances. The nurse then discusses it with the patient and family, modifying it further to conform to their preferences and to obtain their “buy-in.” The final result is an evidence-based, realistic plan that addresses medications, diet, physical activity, self-monitoring, targets, and follow-up. The Care Guide is placed in the medical record and shared with other clinicians, as needed. On the basis of the Care Guide, the nurse then drafts a patient-friendly My Action Plan, which is owned by the patient and displayed in a plastic jacket on the refrigerator or other obvious visible place in the home. This two-page summary reminds the patient when to take medicines, what diet to follow, what exercise to do, when to monitor weight and blood pressure, what to watch out for, and when to see the doctor. 3. Monitoring The nurse then begins the proactive monitoring phase of Guided Care. Rather than waiting for a problem to prompt the patient to access the health care system, the nurse reviews the Action Plan at least monthly with the patient. Most of these contacts are by telephone, but some are in person in the office, at the hospital, or in the home. If the patient doesn't call, the EHR reminds the nurse to call the patient or caregiver. The frequency of nurse's contacts with each patient fluctuates according to need. 4. Coaching During the monitoring contacts, the nurse reviews the patient's self-management, point by point, making certain that all components of the plan are being followed. The nurse uses motivational interviewing techniques to help the patient overcome obstacles. The nurse confers with physicians as needed, making adjustments to the Action Plan and Care Guide. 5. Chronic Disease Self-Management The Guided Care nurse refers most patients to a local “chronic disease self-management” (CDSM) course. The course consists of one two- to two-and-a-half-hour session per week for six weeks. The caregiver classes, which meet weekly for six weeks, provide general information on how to be a caregiver. Following this course, the nurse leads an ongoing monthly support group for caregivers and monitors their status quarterly by telephone. 7. Coordinating Transitions Between Providers and Sites of Care To help coordinate complex care, the Guided Care nurse provides a brief but complete summary of the patient's health and health care (the Care Guide) to the patient's other providers, eg, hospitals, specialists, rehabilitation therapists, and home care nurses. One of the nurse's highest priorities is to smooth transitions between sites of care, especially into and out of hospitals. The nurse monitors the patient and family through the hospital stay and prepares them for discharge before they go home. When they do go home, the nurse visits them on the first day, making sure they have what they need and that they understand how to care for themselves, how to take medications, what to watch for, and that they have necessary contact information—emergency phone numbers and e-mail addresses—should problems or questions arise. 8. Access to Community Services The Guided Care nurse also facilitates patients' access to many services provided by community agencies, such as Meals-on-Wheels, transportation services, senior centers, adult day health centers, and the Alzheimer Association. Patients learn to set and attain health-related goals, interpret their own symptoms, and use the health care system appropriately. Pilot Study We conducted a pilot study for one year to assess the feasibility of providing Guided Care in a community primary care practice. We prepared one nurse, who then worked with two internists and their high-risk older patients in a practice in urban Baltimore, MD. Surveys of the patients who received Guided Care and similar patients who received “usual care” in the practice showed that Guided Care recipients experienced more improvement in the quality of their care than did the usual care group. 8 Insurance claims revealed that the costs of health care were lower for the Guided Care patients than for the usual care patients. 9 Cluster-Randomized Controlled Trial We are now conducting an eight-site cluster-randomized controlled trial of Guided Care involving more than 850 older high-risk patients, 320 family caregivers and 49 community-based primary care physicians. As shown in Table 1, we will compare several outcomes after 6 months and 18 months of Guided Care and usual care. The results of this study will determine the future of Guided Care. This randomized trial of Guided Care is supported by funds from the Agency for Healthcare Research and Quality, the National Institute on Aging, the John A Hartford Foundation, and the Jacob and Valeria Langeloth Foundation. Learn More. This study aimed to measure the effect of guided care teams on multimorbid older patients’ use of health services. Eight services of a guided care nurse working in partnership with patients’ primary care physicians were provided: comprehensive assessment, evidence-based care planning, monthly monitoring of symptoms and adherence, transitional care, coordination of health care professionals, support for self-management, support for family caregivers, and enhanced access to community services. Outcome measures were frequency of use of emergency departments, hospitals, skilled nursing facilities, home health agencies, primary care physician services, and specialty physician services. Results The study included 850 older patients at high risk for using health care heavily in the future. Conclusions Guided care reduces the use of home health care but has little effect on the use of other health services in the short run. Its positive effect on Kaiser-Permanente patients’ use of skilled nursing facilities and other health services is intriguing. This model builds on lessons from its predecessors in providing primary care that includes comprehensive geriatric assessment, evidence-based planning, case management, transitional care, self-management, and caregiver support. Guided care is provided by a team that includes a specially trained registered nurse, 2 to 5 physicians, and members of a primary care office staff. This team provides 8 clinical services to a panel of 50 to 60 of the practice’s older patients at highest risk of using health care heavily during the following year. In this article, we report the effects of guided care on multimorbid older patients’ use of 6 health services through an additional 12 months of the aforementioned cRCT. Hypothesizing that this model of care may affect use differently among patients with differing insurance coverage and among those at different levels of risk, we also explore the effects of guided care on these same services among subgroups of patients defined by 2 characteristics: source of health insurance and baseline risk of using health services heavily in the future. Six teams in 3 practices were operated by Kaiser-Permanente Mid-Atlantic States (KPMAS), a group-model managed care organization; 6 teams in 4 practices were operated by Johns Hopkins Community Physicians (JHCP), a state wide network of community-based practices; and 2 teams in 1 practice were operated by MedStar Physician Partners, a multisite group practice. A detailed description of the study design, which was approved by the 3 relevant institutional review boards, was published previously. 11 RECRUITMENT OF PARTICIPANTS From April 1 through June 30, 2006, we screened the insurance claims of all patients of the 14 teams to identify those who were 65 years or older and at high risk of using health services heavily during the following year, as estimated by the claims-based hierarchical condition category (HCC) predictive model. 17 High risk was equated with HCC scores in the highest quartile of the population of older patients covered by their primary health care insurer. Eligible high-risk patients who provided informed consent completed in-home baseline interviews. RANDOMIZATION Each of the 14 primary care teams included 2 to 5 primary care physicians, their office staff, and their consenting high-risk patients. The study’s statistician, masked to the identities of the teams, randomly allocated 1 of each of the 7 pairs of teams to the guided care group; the other 7 teams constituted the usual care control group. Thus, clusters of patients, rather than individuals, were randomized according to the team of physicians who provided their primary care. TREATMENT GROUPS Registered nurses who had completed a course in guided care nursing 18 joined their assigned primary care teams in May 2006. During the following 6 to 8 months, each guided care nurse was integrated into the practice and established a caseload of 50 to 60 guided care patients. The date on which each patient’s care guide was created was set as his or her start date for receiving guided care. Patients in the usual care group continued to receive care from their established primary care physicians. Their start dates for receiving usual care were assigned to mirror the distribution of the guided care patients’ start dates. MEASURES Information regarding all participants’ baseline characteristics was obtained from prerandomization in-home interviews, and their baseline HCC scores were recalculated from insurance claims from the 12 months immediately preceding their start dates. Data regarding participants’ use of health services during the cRCT were obtained from paid insurance claims. We computed each participant’s annualized use of health services from his or her start date through June 30, 2008. An estimate of the use of long-term custodial nursing home days was obtained from participants’ responses to a telephone interview question 8 and 20 months after their start dates: “How many days did you spend in a nursing home during the past year?” We counted as long-term custodial days only those self-reported nursing home days that exceeded a participant’s days in nursing homes for postacute rehabilitation, as reflected by their insurance claims. STATISTICAL ANALYSIS As described in detail previously, 11 we imputed values for missing responses to baseline interview questions: 5 imputed data sets were generated and inferences were combined across data sets using Rubin’s combining rules. 19 Less than 1 of baseline responses were missing except for the question regarding finances (4 missing). In comparing the 2 study groups at baseline, we used site-stratified testing procedures to evaluate differences in all characteristics except health insurance because of its strong correlation with site. We compared the guided care and usual care patients’ use of health services during the intervals between their start dates and June 30, 2008. For each health service, we constructed a marginal regression model, which accounted for the correlation of multiple outcomes within individuals, 20 to estimate the effect of guided care (vs usual care) on the mean units of service used per person per year. For each service, we constructed an a priori model of the logarithm of the mean rate as a linear function of treatment group, age, race, sex, educational level, finances, HCC score, self-rated health, activities of daily living, instrumental activities of daily living, and practice site, plus an offset term for exposure period. Regression parameters were estimated using generalized estimating equations with a working independence covariance structure. The estimated variance-covariance matrix of all the regression estimators was obtained using the sandwich variance technique. 21, 22 The adjusted treatment effect for each outcome is interpreted as the ratio of themean units of service used per guided care recipient (vs usual care recipient) during a common exposure period. We also estimated an approximate posterior (ie, Bayesian) probability that guided care reduced the use of a service by at least 10.0 by simulating 500 000 draws from a multivariate normal distribution in which the mean was set equal to the estimated regression parameters and the variance-covariance matrix was set equal to the estimated variance-covariance matrix. 23 From these simulations, we computed, for each service, the proportion of effects that yielded greater than 10.0 improvement.