Preliminary Validation of a Patient-Reported Measure of the Age-Friendliness of Health Care.

BACKGROUND/OBJECTIVE: To evaluate the validity and reliability of a patient-reported measure of the "age-friendliness" of health care. DESIGN: Based on four essential domains of high-quality health care for older outpatients (Medications, Mobility, Mentation and "what Matters," i.e., the 4 M's), we drafted a five-item questionnaire for older outpatients to rate the age-friendliness of their health care. One question addressed each of the 4 M's; the fifth addressed the overall age-friendliness of their care. After feedback from healthcare professionals, quality improvement experts, and a patient-caregiver focus group, we revised the items to create the Age-Friendliness Questionnaire (AFQ). SETTING We tested the AFQ by appending it to two surveys. PARTICIPANTS: Older outpatients in Idaho during July to October 2019: Survey 1, with 23 other items, was sent to 1,257 older patients who were medically complex; Survey 2, with 35 other items, was sent to 2,873 older patients who visited outpatient primary care providers (PCPs) during the specified time period. MEASUREMENTS: Respondents rated their providers' performance using a 1 to 5 ("never" to "always") scale for each of the five items (possible AFQ scores = 5-25). RESULTS: The response rates were 41.4% and 33.3%, respectively. In Survey 1, the mean AFQ score from patients who had received care from a geriatrics consult clinic was higher than that from patients who had received their care from PCPs (19.3 vs 15.6; P < .001), and AFQ scores correlated with other quality-of-care scores. In Survey 2, AFQ scores predicted respondents' likelihood of recommending their providers to others (P < .001). The AFQ exhibited high internal reliability (interitem correlations = .49-.77; Cronbach's α = .89). CONCLUSION: The AFQ appears to be a valid and reliable measure of the age-friendliness of outpatient care for older patients, and it predicts the likelihood that they will recommend their providers to others.

Effect of a Multifactorial Fall Injury Prevention Intervention on Patient Well-Being: The STRIDE Study.

BACKGROUND/OBJECTIVES: In the Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) study, a multifactorial intervention was associated with a nonsignificant 8% reduction in time to first serious fall injury but a significant 10% reduction in time to first self-reported fall injury relative to enhanced usual care. The effect of the intervention on other outcomes important to patients has not yet been reported. We aimed to evaluate the effect of the intervention on patient well-being including concern about falling, anxiety, depression, physical function, and disability. DESIGN: Pragmatic cluster-randomized trial of 5,451 community-living persons at high risk for serious fall injuries. SETTING: A total of 86 primary care practices within 10 U.S. healthcare systems. PARTICIPANTS: A random subsample of 743 persons aged 75 and older. MEASUREMENTS: The well-being measures, assessed at baseline, 12 months, and 24 months, included a modified version of the Fall Efficacy Scale, Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety and depression scales, and Late-Life Function and Disability Instrument. RESULTS: Participants in the intervention (n = 384) and control groups (n = 359) were comparable in age: mean (standard deviation) of 81.9 (4.7) versus 81.8 (5.0) years. Mean scores were similar between groups at 12 and 24 months for concern about falling, physical function, and disability, whereas the intervention group's mean scores on anxiety and depression were .7 points lower (i.e., better) at 12 months and .6 to .8 points lower at 24 months. For each of these outcomes, differences between the groups' adjusted least square mean changes from baseline to 12 and 24 months, respectively, were quantitatively small. The overall difference in means between groups over 2 years was statistically significant only for depression, favoring the intervention: -1.19 (99% confidence interval, -2.36 to -.02), with 3.5 points representing a minimally important difference. CONCLUSIONS: STRIDE's multifactorial intervention to reduce fall injuries was not associated with clinically meaningful improvements in patient well-being.

A Randomized Trial of a Multifactorial Strategy to Prevent Serious Fall Injuries.

BACKGROUND: Injuries from falls are major contributors to complications and death in older adults. Despite evidence from efficacy trials that many falls can be prevented, rates of falls resulting in injury have not declined. METHODS: We conducted a pragmatic, cluster-randomized trial to evaluate the effectiveness of a multifactorial intervention that included risk assessment and individualized plans, administered by specially trained nurses, to prevent fall injuries. A total of 86 primary care practices across 10 health care systems were randomly assigned to the intervention or to enhanced usual care (the control) (43 practices each). The participants were community-dwelling adults, 70 years of age or older, who were at increased risk for fall injuries. The primary outcome, assessed in a time-to-event analysis, was the first serious fall injury, adjudicated with the use of participant report, electronic health records, and claims data. We hypothesized that the event rate would be lower by 20% in the intervention group than in the control group. RESULTS: The demographic and baseline characteristics of the participants were similar in the intervention group (2802 participants) and the control group (2649 participants); the mean age was 80 years, and 62.0% of the participants were women. The rate of a first adjudicated serious fall injury did not differ significantly between the groups, as assessed in a time-to-first-event analysis (events per 100 person-years of follow-up, 4.9 in the intervention group and 5.3 in the control group; hazard ratio, 0.92; 95% confidence interval [CI], 0.80 to 1.06; P = 0.25). The rate of a first participant-reported fall injury was 25.6 events per 100 person-years of follow-up in the intervention group and 28.6 events per 100 person-years of follow-up in the control group (hazard ratio, 0.90; 95% CI, 0.83 to 0.99; P = 0.004). The rates of hospitalization or death were similar in the two groups. CONCLUSIONS: A multifactorial intervention, administered by nurses, did not result in a significantly lower rate of a first adjudicated serious fall injury than enhanced usual care. (Funded by the Patient-Centered Outcomes Research Institute and others; STRIDE ClinicalTrials.gov number, NCT02475850.).

The Strategies to Reduce Injuries and Develop Confidence in Elders Intervention: Falls Risk Factor Assessment and Management, Patient Engagement, and Nurse Co-management.

In response to the epidemic of falls and serious falls-related injuries in older persons, in 2014, the Patient Centered Outcomes Research Institute (PCORI) and the National Institute on Aging funded a pragmatic trial, Strategies to Reduce Injuries and Develop confidence in Elders (STRIDE) to compare the effects of a multifactorial intervention with those of an enhanced usual care intervention. The STRIDE multifactorial intervention consists of five major components that registered nurses deliver in the role of falls care managers, co-managing fall risk in partnership with patients and their primary care providers (PCPs). The components include a standardized assessment of eight modifiable risk factors (medications; postural hypotension; feet and footwear; vision; vitamin D; osteoporosis; home safety; strength, gait, and balance impairment) and the use of protocols and algorithms to generate recommended management of risk factors; explanation of assessment results to the patient (and caregiver when appropriate) using basic motivational interviewing techniques to elicit patient priorities, preferences, and readiness to participate in treatments; co-creation of individualized falls care plans that patients' PCPs review, modify, and approve; implementation of the falls care plan; and ongoing monitoring of response, regularly scheduled re-assessments of fall risk, and revisions of the falls care plan. Custom-designed falls care management software facilitates risk factor assessment, the identification of recommended interventions, clinic note generation, and longitudinal care management. The trial testing the effectiveness of the STRIDE intervention is in progress, with results expected in late 2019.

Healthcare task difficulty among older adults with multimorbidity.

BACKGROUND: Applying disease-specific guidelines to people with multimorbidity may result in complex regimens that impose treatment burden. OBJECTIVES: To describe and validate a measure of healthcare task difficulty (HCTD) in a sample of older adults with multimorbidity. RESEARCH DESIGN: Cross-sectional and longitudinal secondary data analysis. SUBJECTS: Multimorbid adults aged 65 years or older from primary care clinics. MEASURES: We generated a scale (0-16) of self-reported difficulty with 8 HCTD and conducted factor analysis to assess its dimensionality and internal consistency. To assess predictive ability, cross-sectional associations of HCTD and number of chronic diseases, and conditions that add to health status complexity (falls, visual, and hearing impairment), patient activation, patient-reported quality of chronic illness care (Patient Assessment of Chronic Illness Care), mental and physical health (SF-36) were tested using statistical tests for trend (n=904). Longitudinal analyses of the effects of change in HCTD on changes in the outcomes were conducted among a subset (n=370) with ≥1 follow-up at 6 and/or 18 months. All models were adjusted for age, education, sex, race, and time. RESULTS: Greater HCTD was associated with worse mental and physical health [Cuzick test for trend (P<0.05)], and patient-reported quality of chronic illness care (P<0.05). In longitudinal analysis, increasing patient activation was associated with declining HCTD over time (P<0.01). Increasing HCTD over time was associated with declining mental (P<0.001) and physical health (P=0.001) and patient-reported quality of chronic illness care (P<0.05). CONCLUSIONS: The findings of this study establish the construct validity of the HCTD scale.

Do older patients and their family caregivers agree about the quality of chronic illness care?

OBJECTIVE: Family caregivers often accompany patients to medical visits; however, it is unclear whether caregivers rate the quality of patients' care similarly to patients. This study aimed to (1) quantify the level of agreement between patients' and caregivers' reports on the quality of patients' care and (2) determine how the level of agreement varies by caregiver and patient characteristics. DESIGN: Cross-sectional analysis. PARTICIPANTS: Multimorbid older (aged 65 and above) adults and their family caregivers (n = 247). METHODS: Quality of care was rated separately by patients and their caregivers using the Patient Assessment of Chronic Illness Care (PACIC) instrument. The level of agreement was examined using a weighted kappa statistic (Kw). RESULTS: Agreement of caregivers' and patients' PACIC scores was low (Kw = 0.15). Patients taking ten or more medications per day showed less agreement with their caregivers about the quality of care than patients taking five or fewer medications (Kw = 0.03 and 0.34, respectively, P < 0.05). Caregivers who reported greater difficulty assisting patients with health care tasks had less agreement with patients about the quality of care being provided when compared with caregivers who reported no difficulty (Kw = -0.05 and 0.31, respectively, P < .05). Patient-caregiver dyads had greater agreement on objective questions than on subjective questions (Kw = 0.25 and 0.15, respectively, P > 0.05). CONCLUSION: Patient-caregiver dyads following a more complex treatment plan (i.e. taking many medications) or having more difficulty following a treatment plan (i.e. having difficulty with health care tasks) had less agreement. Future qualitative research is needed to elucidate the underlying reasons patients and caregivers rate the quality of care differently.

Effects of Guided Care on providers' satisfaction with care: a three-year matched-pair cluster-randomized trial.

It is important to understand the effects of a new care model on health professionals' satisfaction, which may help inform organizations' decisions regarding the adoption of the model. This study evaluates the effect of the Guided Care model of primary care on physicians', Guided Care Nurses' and practice staff satisfaction with processes of care for chronically ill older patients. In Guided Care, a specially educated registered nurse works with 2-5 primary care physicians, performing 8 clinical activities for 50-60 chronically ill older patients. This model was tested in a 3-year matched-pair cluster-randomized controlled trial with 14 pods (teams of physicians and staff) randomly assigned, within pairs, to provide Guided Care or usual care. Physicians and Guided Care Nurses were surveyed at baseline and annually for 3 years. Staff were surveyed at baseline and 2 years later. Physicians' satisfaction with chronic care processes, knowledge of patients, and care coordination were measured, as well as Guided Care Nurses' satisfaction with chronic care processes and staff perceptions of quality of care. Findings suggest that Guided Care improved physician satisfaction with patient/family communication and management of chronic care, and it may bolster staff beliefs that care is patient oriented. Differences in other aspects of care were not statistically significant.

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

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.

Who participates in chronic disease self-management (CDSM) programs? Differences between participants and nonparticipants in a population of multimorbid older adults.

BACKGROUND: Self-care management is recognized as a key component of care for multimorbid older adults; however, the characteristics of those most likely to participate in Chronic Disease Self-Management (CDSM) programs and strategies to maximize participation in such programs are unknown. OBJECTIVES: To identify individual factors associated with attending CDSM programs in a sample of multimorbid older adults. RESEARCH DESIGN: Participants in the intervention arm of a matched-pair cluster-randomized controlled trial of the Guided Care model were invited to attend a 6-session CDSM course. Logistic regression was used to identify factors independently associated with attendance. SUBJECTS: All subjects (N = 241) were aged 65 years or older, were at high risk for health care utilization, and were not homebound. MEASURES: Baseline information on demographics, health status, health activities, and quality of care was available for CDSM participants and nonparticipants. Participation was defined as attendance at 5 or more CDSM sessions. RESULTS: A total of 22.8% of multimorbid older adults who were invited to CDSM courses participated in 5 or more sessions. Having better physical health (odds ratio [95% confidence interval] = 2.3 [1.1-4.8]) and rating one's physician poorly on support for patient activation (odds ratio [95% confidence interval] = 2.8 [1.3-6.0]) were independently associated with attendance. CONCLUSIONS: Multimorbid older adults who are in better physical health and who are dissatisfied with their physicians' support for patient activation are more likely to participate in CDSM courses.

Difficulty assisting with health care tasks among caregivers of multimorbid older adults.

BACKGROUND: Family caregivers provide assistance with health care tasks for many older adults with chronic illnesses. The difficulty they experience in providing this assistance, and related implications for their well-being, have not been well described. OBJECTIVE: The objectives of this study are: (1) to describe caregiver's health care task difficulty (HCTD), (2) determine the characteristics associated with HCTD, and (3) explore the association between HCTD and caregiver well-being. DESIGN: This is a cross-sectional study. PARTICIPANTS: Baseline sample of caregivers to older (aged 65+ years) multimorbid adults enrolled in an ongoing cluster-randomized controlled trial (N = 308). MAIN MEASURES: The HCTD scale (0-16) is comprised of questions measuring self-reported difficulty in assisting older adults with eight health care tasks, including taking medication, visiting health care providers, and managing medical bills. Caregivers were categorized using this scale into no, low, medium, and high HCTD groups. We used ordinal logistic regression and multivariate linear regression analyses to examine the relationships between HCTD, caregiver self-efficacy, caregiver strain (Caregiver Strain Index), and depression (Center for Epidemiological Studies Depression Scale), controlling for patient and caregiver socio-demographic and health factors. KEY RESULTS: Caregiver age and number of health care tasks performed were positively associated with increased HCTD. The quality of the caregiver's relationship with the patient, and self-efficacy were inversely associated with increased HCTD. A one-point increase in self-efficacy was associated with a significant lower odds of reporting high HCTD (OR, 0.64; 95% CI, 0.54, 0.77).Adjusted linear regression models indicated that high HCTD was independently associated with significantly greater caregiver strain (B, 2.7; 95% CI, 1.12, 4.29) and depression (B, 3.01; 95% CI, 1.06, 4.96). CONCLUSIONS: This study demonstrates that greater HCTD is associated with increased strain and depression among caregivers of multimorbid older adults. That caregiver self-efficacy was strongly associated with HCTD suggests health-system-based educational and empowering interventions might improve caregiver well-being.

The effect of guided care teams on the use of health services: results from a cluster-randomized controlled trial.

BACKGROUND: The effect of interdisciplinary primary care teams on the use of health services by patients with multiple chronic conditions is uncertain. This study aimed to measure the effect of guided care teams on multimorbid older patients' use of health services. METHODS: Eligible patients from 3 health care systems in the Baltimore, Maryland-Washington, DC, area were cluster-randomized to receive guided care or usual care for 20 months between November 1, 2006, and June 30, 2008. 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. The only statistically significant overall effect of guided care in the whole sample was a reduction in episodes of home health care (odds ratio, 0.70; 95% confidence interval, 0.53-0.93). In a preplanned analysis, guided care also reduced skilled nursing facility admissions (odds ratio, 0.53; 95% confidence interval, 0.31-0.89) and days (0.48; 0.28-0.84) among Kaiser-Permanente patients. 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. Trial Registration clinicaltrials.gov Identifier: NCT00121940.

Psychometric properties of the patient activation measure among multimorbid older adults.

OBJECTIVES: The Patient Activation Measure (PAM) quantifies the extent to which people are informed about and involved in their health care. Objectives were to determine the psychometric properties of PAM among multimorbid older adults and evaluate a theoretical, four-stage model of patient activation. Methods. A cross-sectional analysis was used to assess the psychometric properties of PAM. Internal consistency was assessed using Cronbach α. Construct validity was evaluated using general linear modeling to compute associations between PAM scores and health-related behaviors, functional status, and health care quality. Latent class analysis was used to evaluate the theoretical four-stage structure of patient activation. STUDY SETTING: Participants in a randomized trial of Guided Care (N = 855), a model of comprehensive health care for older adults with chronic conditions that put them at risk of using health services heavily during the coming year. PRINCIPAL FINDINGS: Higher PAM activation scores and stage were positively associated with higher functional status, health care quality, and adherence to some health behaviors. Latent class analysis supported the multistage theory of patient activation. CONCLUSIONS: The PAM is a reliable, valid, and potentially clinically useful measure of patient activation for multimorbid older adults.

Comprehensive primary care for older patients with multiple chronic conditions: "Nobody rushes you through".

Older patients with multiple chronic health conditions and complex health care needs often receive care that is fragmented, incomplete, inefficient, and ineffective. This article describes the case of an older woman whose case cannot be managed effectively through the customary approach of simply diagnosing and treating her individual diseases. Based on expert consensus about the available evidence, this article identifies 4 proactive, continuous processes that can substantially improve the primary care of community-dwelling older patients who have multiple chronic conditions: comprehensive assessment, evidence-based care planning and monitoring, promotion of patients' and (family caregivers') active engagement in care, and coordination of professionals in care of the patient--all tailored to the patient's goals and preferences. Three models of chronic care that include these processes and that appear to improve some aspects of the effectiveness and the efficiency of complex primary care--the Geriatric Resources for Assessment and Care of Elders (GRACE) model, Guided Care, and the Program of All-inclusive Care for the Elderly (PACE)--are described briefly, and steps toward their implementation are discussed.

Physician satisfaction with chronic care processes: a cluster-randomized trial of guided care.

PURPOSE: Chronically ill older patients with multiple conditions are challenging to care for, and new models of care for this population are needed. This study evaluates the effect of the Guided Care model on primary care physicians' impressions of processes of care for chronically ill older patients. METHODS: In Guided Care a specially educated registered nurse works at the practice with 2 to 5 primary care physicians, performing 8 clinical activities for 50 to 60 chronically ill older patients. The care model was tested in a cluster-randomized controlled trial between 2006 and 2009. All eligible primary care physicians in 14 pods (teams of physicians and their chronically ill older patients) agreed to participate (n = 49). Pods were randomly assigned to provide either Guided Care or usual care. Physicians were surveyed at baseline and 1 year later. We assessed the effects of Guided Care using responses from 38 physicians who completed both survey questionnaires. We measured physicians' satisfaction with chronic care processes, time spent on chronic care, knowledge of their chronically ill older patients, and care coordination provided by physicians and office staff. RESULTS: Compared with the physicians in the control group, those in the Guided Care group rated their satisfaction with patient/family communication and their knowledge of the clinical characteristics of their chronically ill older patients significantly higher (rho<0.05 in linear regression models). Other differences did not reach statistical significance. CONCLUSIONS: Based on physician report, Guided Care provides important benefits to physicians by improving communication with chronically ill older patients and their families and in physicians' knowledge of their patients' clinical conditions.

The urgency of preparing primary care physicians to care for older people with chronic illnesses.

Population trends are driving an undeniable imperative: The United States must begin training its primary care physicians to provide higher-quality, more cost-effective care to older people with chronic conditions. Doing so will require aggressive initiatives to educate primary care physicians to apply principles of geriatrics--for example, optimizing functional autonomy and quality of life--within emerging models of chronic care. Policy options to drive such reforms include the following: providing financial support for medical schools and residency programs that adopt appropriate educational innovations; tailoring Medicare's educational subsidy to reform graduate medical education; and invoking state requirements that physicians obtain geriatric continuing education credits to maintain their licensure or to practice as Medicaid providers or medical directors of nursing homes. This paper also argues that the expertise of geriatricians could be broadened to include educational and leadership skills. These geriatrician-leaders could then become teachers in the educational programs of many disciplines. This would require changes inside and outside academic medicine.

The geriatric floating interdisciplinary transition team.

Older adults often receive suboptimal care during hospitalizations and transitions to postacute settings. Inpatient geriatric services have been shown to increase care quality but have not improved patient outcomes consistently. Acute Care for the Elderly units improve patient outcomes but are resource intensive. Transitional care has been shown to reduce hospital readmissions and healthcare costs. This article describes the Geriatric Floating Interdisciplinary Transition Team (Geri-FITT), a model that combines the strengths of inpatient geriatric evaluation and comanagement and transitional care models by creating an inpatient comanagement service that also delivers transitional care. The Geri-FITT model is designed to improve the hospital care of older adults and their transitions to postacute settings. In Geri-FITT, a geriatrician-geriatric nurse practitioner team assesses patients, comanages geriatric syndromes, provides staff education, encourages patient self-management, communicates with primary care providers, and follows up with patients soon after discharge. This pilot cohort study of Geri-FITT included hospitalized patients aged 70 and older on four general medicine services (two Geri-FITT, two usual care) at an academic medical center (N=717). The study assessed the effect of Geri-FITT on patients' care transition quality (Care Transitions Measure) and their satisfaction with hospital care (four questions). The results indicate that Geri-FITT is associated with slightly higher, though not statistically significantly so, quality care transitions and greater patient satisfaction with inpatient care. Geri-FITT may be a feasible approach to enhancing inpatient management and transitional care for older adults. Further study of its effect on these and other outcomes in other healthcare settings seems warranted.

Effects of guided care on family caregivers.

PURPOSE: Guided Care (GC) is a model of health care for multimorbid older adults that is provided by a registered nurse who works with the patients' primary care physician (PCP). The purpose of this study was to determine whether GC improves patients' primary caregivers' depressive symptoms, strain, productivity, and perceptions of the quality of care recipients' chronic illness care. DESIGN AND METHODS: A cluster-randomized controlled trial of GC was conducted within 14 PCP teams. The study sample included 196 primary caregivers who completed baseline and 18-month surveys and whose care recipients remained alive and enrolled in the GC study for 18 months. Caregiver outcomes included the following: depressive symptoms (Center for Epidemiological Studies-Depression scale), strain (Modified Caregiver Strain Index), the quality of care recipients' chronic illness care [Patient Assessment of Chronic Illness Care (PACIC)], and personal productivity (Work Productivity and Activity Impairment questionnaire, adapted for caregiving). RESULTS: In multivariate regression models, between-group differences in depression, strain, work productivity, and regular activity productivity were not statistically significant after 18 months, but GC caregivers reported the overall quality of their recipients' chronic illness care to be significantly higher (adjusted beta = 0.40, 95% confidence interval : 0.14-0.67). Quality was significantly higher in 4 of 5 PACIC subscales, reflecting the dimensions of goal setting, coordination of care, decision support, and patient activation. IMPLICATIONS: GC improved the quality of chronic illness care received by multimorbid care recipients but did not improve caregivers' depressive symptoms, affect, or productivity.

The effects of guided care on the perceived quality of health care for multi-morbid older persons: 18-month outcomes from a cluster-randomized controlled trial.

BACKGROUND: The quality of health care for older Americans with chronic conditions is suboptimal. OBJECTIVE: To evaluate the effects of "Guided Care" on patient-reported quality of chronic illness care. DESIGN: Cluster-randomized controlled trial of Guided Care in 14 primary care teams. PARTICIPANTS: Older patients of these teams were eligible to participate if, based on analysis of their recent insurance claims, they were at risk for incurring high health-care costs during the coming year. Small teams of physicians and their at-risk older patients were randomized to receive either Guided Care (GC) or usual care (UC). INTERVENTION: "Guided Care" is designed to enhance the quality of health care by integrating a registered nurse, trained in chronic care, into a primary care practice to work with 2-5 physicians in providing comprehensive chronic care to 50-60 multi-morbid older patients. MEASUREMENTS: Eighteen months after baseline, interviewers blinded to group assignment administered the Patient Assessment of Chronic Illness Care (PACIC) survey by telephone. Logistic and linear regression was used to evaluate the effect of the intervention on patient-reported quality of chronic illness care. RESULTS: Of the 13,534 older patients screened, 2,391 (17.7%) were eligible to participate in the study, of which 904 (37.8%) gave informed consent and were cluster-randomized. After 18 months, 95.3% and 92.2% of the GC and UC recipients who remained alive and eligible completed interviews. Compared to UC recipients, GC recipients had twice greater odds of rating their chronic care highly (aOR = 2.13, 95% CI = 1.30-3.50, p = 0.003). CONCLUSION: Guided Care improves self-reported quality of chronic health care for multi-morbid older persons.