Masters of Ageing: Dr. Chad Boult

A quarter of all older people have four or more chronic health conditions, resulting in a need for complex health care that is very expensive. Recent research has suggested that enhancing primary health care in several ways could improve the quality of such chronic care and reduce its costs.
Guided Care is a nursing-enhanced model of comprehensive primary care for this population, which was recently tested. The results showed that it improved the quality of chronic care and physicians’ satisfaction with the care they provided. In integrated systems of care, guided care also reduced the use of hospitals and nursing homes.

On Tuesday 9 April Dr. Chad Boult gave a comprehensive lecture about caring for older persons with multiple chronic conditions. Dr. Boult outlined that persons with 4 or more chronic conditions, about 20 to 25% of the population, use approximately 80% of health care budget nowadays. This is related to many issues, but mainly, he argued, associated with numerous factors of mismatch in the organization and structure of health care. For instance, this chronically ill population is characterized by a high number of hospitalizations, caused by a frequent relapse after hospitalizations. Some, he described, are at the hospital more than 50 times a year, partly because the current system is not responsive to their needs.
Dr. Boult argued that our current health care is fragmented, discontinuous, difficult to access, inefficient, unsafe and expensive. In an illustrative quotation, he cited the American health care analyst Donald Berwick “Every system is designed perfectly to produce the results it gets”: The current system does not fit our chronically ill population and is mainly targeted at curing and not at caring. This produces a mismatch that increases costs. In an attempt to find alternative models, Dr. Boult and his team developed the guided care model.

In this model, guided care nurses work in a team with a physician to care for the 50-60 high risk patients with chronic conditions and complex health care needs. Nurses start by assessing needs and more importantly also patients’ preferences and priorities. From this they develop a care plan that is converted in an action plan in lay language for the patient. Instead of awaiting calls by the patient they proactively monitor the patient and create a close connection with the patient. They involve them in their own care, make them responsible for their own health, but also support and motivate them. Especially important in this regard are the transitions between different care institutions, such as from the hospital to the home and vice versa and the access to community services. The nurses also communicate with all the providers and caregivers involved.
The guided care model was researched in a trial involving more than 900 patients (485 in guided care and 419 in usual care). Results were positive, especially in regard to patient satisfaction, reductions of hospitalisations and reductions in caregiver strain. Physician satisfaction in the intervention group was also larger than in the usual care. Finally, after calculation of cost differences guided care proved to be 75.000 dollars cheaper per caseload than usual care.

Despite these promising results, it has not yet been further rolled out in the USA. Kaiser Permanente, a large insurance company owning its own health care facilities intends to further use the model. Dr. Boult related the slow furthering of this to one of the main problems of the structure of financing: savings are made on the side of the hospital, whereas the cost for this guided care model is paid by the primary care. As these two systems do not transfer money from one to another, the model is hard to implement.

In the discussion that followed, the application of the guided care model for the Netherlands was debated. Overall, many similarities were seen in the Dutch system, for instance with guided care nurses were compared to nurse practitioners or the role of neighborhood nurses. Moreover, in many instances general practitioners tend to take on the role of the guided care nurses as the point of reference for the patient. In the Netherlands, furthermore, similar financing problems would be the case.

Finally, Prof. Rudi Westendorp commented that in a discussion with one of the biggest health care insurers in the Netherlands exactly this point was raised and it was felt that the time has come to make a step towards changing this system.
All in all, the guided care model was seen as a promising model. The systematic barriers that currently still exist however, pose a large challenge for the actual implementation of these kinds of models. A change must be made to be responsive to the needs and wishes of our changing health care population.

Dr. Chad Boult is a teacher, researcher and board-certified physician in Family Medicine and Geriatrics. Dr. Boult has extensive experience in developing, testing, evaluating and diffusing new models of health care for older persons with chronic conditions. He has published two books and more than 80 articles in biomedical scientific journals. In 2009 and 2010 dr. Boult served as a ‘Health and Aging Policy Fellow’ at the Centers for Medicare & Medicaid Services (CMS).