KEY FEATURE. Specially trained nurses create care plans, educate and support patients and their caregivers, and coordinate care among providers, using formal assessment and planning tools to set priorities for stabilizing health and achieving patients' goals. TARGET POPULATION. Adults at risk of complications from multiple chronic conditions. WHY IT'S IMPORTANT. Medicare beneficiaries with multiple chronic conditions account for the majority of program spending; many feel overwhelmed by their treatment regimens and suffer when their care is not well coordinated. BENEFITS. Promotes patients' ability to manage their conditions and helps them navigate the health care system. Lahey Health in Massachusetts credits Guided Care with helping it achieve a 22 percent reduction in hospital admissions per thousand, leading to shared savings in an accountable care contract with Medicare. LESSONS. In chronic care management programs such as this, it is difficult to determine what level of support (and therefore what program investment) is most effective; different patients may need different levels of support.
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