A matched-pair cluster-randomized trial of guided care for high-risk older patients

J Gen Intern Med. 2013 May;28(5):612-21. doi: 10.1007/s11606-012-2287-y.


Background: Patients at risk for generating high health care expenditures often receive fragmented, low-quality, inefficient health care. Guided Care is designed to provide proactive, coordinated, comprehensive care for such patients.

Objective: We hypothesized that Guided Care, compared to usual care, produces better functional health and quality of care, while reducing the use of expensive health services.

Design: 32-month, single-blind, matched-pair, cluster-randomized controlled trial of Guided Care, conducted in eight community-based primary care practices.

Patients: The "Hierarchical Condition Category" (HCC) predictive model was used to identify high-risk older patients who were insured by fee-for-service Medicare, a Medicare Advantage plan or Tricare. Patients with HCC scores in the highest quartile (at risk for generating high health care expenditures during the coming year) were eligible to participate.

Intervention: A registered nurse collaborated with two to five primary care physicians in providing eight services to participants: comprehensive assessment, evidence-based care planning, proactive monitoring, care coordination, transitional care, coaching for self-management, caregiver support, and access to community-based services.

Main measures: Functional health was measured using the Short Form-36. Quality of care and health services utilization were measured using the Patient Assessment of Chronic Illness Care and health insurance claims, respectively.

Key results: Of the eligible patients, 904 (37.8 %) gave written consent to participate; of these, 477 (52.8 %) completed the final interview, and 848 (93.8 %) provided complete claims data. In intention-to-treat analyses, Guided Care did not significantly improve participants' functional health, but it was associated with significantly higher participant ratings of the quality of care (difference = 0.27, 95 % CI = 0.08-0.45) and 29 % lower use of home care (95 % CI = 3-48 %).

Conclusions: Guided Care improves high-risk older patients' ratings of the quality of their care, and it reduces their use of home care, but it does not appear to improve their functional health.

Publication types

  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Aged
  • Community Health Services / organization & administration*
  • Community Health Services / standards
  • Delivery of Health Care, Integrated / organization & administration*
  • Delivery of Health Care, Integrated / standards
  • Female
  • Health Expenditures / statistics & numerical data
  • Health Services / statistics & numerical data
  • Health Services for the Aged / organization & administration*
  • Health Services for the Aged / standards
  • Humans
  • Male
  • Patient Satisfaction
  • Primary Health Care / organization & administration*
  • Primary Health Care / standards
  • Quality of Health Care
  • Single-Blind Method
  • United States