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case management, chronic disease, multimorbidity, nursing, primary care



  1. Aliotta, Sherry L. BSN, RN, CCM
  2. Grieve, Kathleen RN, BSN, MHA, CCM
  3. Giddens, Jean F. PhD, RN
  4. Dunbar, Linda PhD, RN
  5. Groves, Carol RN
  6. Frey, Katherine MPH
  7. Boult, Chad MD, MPH, MBA


Purpose: This article describes "Guided Care," a promising new model of case management that includes disease management, self-management, transitional care, and caregiver support for multimorbid patients and their families.


Primary Practice Settings: Guided Care nurses, based at primary care practices, extend services to the home and all the other settings where their patients receive care.


Findings and Conclusions: Guided Care nurses take responsibility for 50-60 multimorbid patients. For each patient, the nurse performs a home assessment and creates an evidence-based plan of care. In partnership with the primary physician, the Guided Care nurse then monitors and coaches the patient monthly, coordinates the patient's transitions between providers and sites of care, educates and supports family caregivers, and facilitates access to community resources.


Implications for Case Management Practice: As a next stage in the evolution of case management, Guided Care may be supported by Medicare and, therefore, adopted widely throughout the American healthcare.