Guided Care is a model of proactive, comprehensive health care that can help primary care practices transform into patient-centered medical homes. Guided Care focuses on improving care for patients with multiple chronic health conditions. Guided Care teams include a registered nurse, two to five physicians, and other members of the office staff who work together to perform home-based assessments, create an evidence-based care guide and action plan, monitor and coach the patient monthly, coordinate the efforts of all the patient's healthcare providers, smooth transitions between sites of care, promote patient self-management, educate and support family caregivers, and facilitate access to community resources.