GC is a novel care model to enhance primary care for older, multimorbid adults that incorporates all major elements of chronic illness management. In this pilot study, our results suggest that patients who received a pilot version of GC may have experienced improvements in specific aspects of the quality of their primary care experiences. The results of this pilot study must be interpreted with caution, but they may inform the important topics of designing interventions for the vulnerable population of older adults with complex chronic illness and evaluating the effectiveness of models of care for this population.
The pilot version of GC addressed salient needs of older patients with complex chronic illness including redesign of the delivery system to enhance primary care using a specially educated nurse working in conjunction with PCPs across multiple health conditions and needs; it incorporated improved decision support and clinical information systems and better access to community resources. Importantly, the full model of GC currently being tested in an on-going RCT also includes a chronic disease self-management program and a formal program for education and support of caregivers.
There are several caveats to this work. First, this was a pilot study, designed to test the feasibility of implementing GC. It was not designed or powered to establish whether GC improved quality of primary care experiences definitively. Second, although our data suggest that GC improves the quality of primary care experiences, we assessed quality of primary care through patient self-report. This method is justified given the importance of patient-centered care.38,39
Disease-specific quality of primary care is also potentially less relevant to this older population with substantial multimorbidity, given the lack of evidence on what constitutes high-quality disease-specific process measures for older people with multimorbidity.40,41
A larger RCT of the full model of GC, powered on the outcome of quality of life, will evaluate effects of GC on quality of primary care.
Third, the costs of GC in the pilot study included the nurse’s salary and benefits, training, a laptop computer, information technology, office space, and travel to patients’ homes. A detailed assessment of the cost of GC is now being conducted in the ongoing RCT. Fourth, based on risk of health care utilization, the intervention group appeared to be sicker at baseline. Fifth, all participants were members of a managed care plan seen by 2 Internists at a community practice and are not representative of all older adults. Sixth, treatment assignment was dictated by physician pair. Unequal treatment by physician pairs cannot be excluded as a potential source of bias, although this would not be expected to change differentially over time. Finally, there was lower than expected enrollment of intervention patients into the caseload of the GCN because of a variety of factors described above. However, data suggest these patients were not different from enrolled patients except for having fewer chronic diseases and better self-rated health.
Several lessons were learned from this pilot study that have informed the RCT of GC and may be useful to others designing interventions for older adults with complex chronic illness.32
First, integrating the GCN into the work flow of the office practice required several months of orientation and problem-solving. The support of the physicians, who were initially skeptical about GC, was essential in developing effective teamwork in the practice and individualizing care. Introductory letters from physicians increased their patients’ interest in participating. In the larger ongoing trial of GC, 90% of patients randomized to receive GC are actually receiving it. In informal debriefings at the end of the pilot year, the physicians expressed enthusiasm for GC and a strong desire to work with a GCN in the future and observed that the GCN had improved the quality of their patients’ chronic care, especially communication and coordination among providers. They estimated that the time they devoted to communicating with the GCN had been offset equally by reductions in the time they devoted to unreimbursed tasks of care and care coordination. Anecdotal reports indicated that the patients and families were happy to have received GC.
Second, based on our experience in the pilot and the early phases of the RCT, the curriculum that prepares registered nurses to practice GC should emphasize topics that are specific to GC and review topics related to traditional nursing in less detail. The curriculum has been reduced to 3 weeks, with the specific intent of meeting the key educational objectives and improving the ultimate dissemination and scalability of GC. Although there is a shortage of hospital nurses in the U.S., the supply of nurses interested in community-based
positions may be sufficient. “Integrated practice models across practice settings” are thought to be a key strategy for attracting and retaining qualified candidates for careers in nursing.42
Finally, fidelity to multifaceted clinical models is challenging to maintain, especially during dissemination. In the ongoing RCT of GC, several processes promote fidelity and consistency among the various GCNs and practice sites: continuous GCN performance monitoring (via the EHR, insurance claims, and patient surveys), periodic interviews with GC physicians, monthly feedback of performance results to GCNs, and monthly group meetings of GCNs and supervisors.
In summary, this pilot test supports the feasibility and acceptability of recruiting, training, and deploying a GCN to implement 6 of the 8 major components of the GC model. A 2-year cluster-randomized trial of GC is now underway, funded by the John A. Hartford Foundation, the Agency for Healthcare Research and Quality, the National Institute on Aging, and the Jacob and Valeria Langeloth Foundation. Despite the limitations described above, these pilot data suggest that GC holds promise as an intervention that will improve the quality of primary care experiences for older people with complex care needs. GC is designed to be disseminated into widespread practice if the larger RCT proves successful at improving quality of life and the quality and efficiency of care.