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Guided Care plan reduces costs for chronically ill seniors

Seniors with chronic illnesses represent an especially challenging subset of patients, especially for capitated Medicare Advantage HMOs. In a program designed by a multidisciplinary team of clinicians and researchers at Johns Hopkins University Bloomberg School of Public Health in Baltimore, specially trained nurses work in PCP offices to coordinate the care of older adults with multiple chronic illnesses, facilitate transitions in care, and serve as patient advocates across healthcare and social settings.