Team Care For Chronic Disease
Patients: Using Lay “Care Guides”
Allina Health
Friday February 21, 2014
1 – 2 p.m. CST
RARE Webinar
Team Care For Chronic Disease Patients: Using Lay “Care Guides”
Division of Applied Research
Part of Allina's Office of Clinical Excellence
We engage in practice-based research and
innovation in service to Allina's patients,
families, communities, and providers. Our
purpose is to design, evaluate, and disseminate
innovative strategies to improve care delivery
and enhance population health
Link to care guide video: http://bcove.me/mb8jig9d
Team-based Care Models
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Chronic disease model
Patient-centered medical home
Teamlet model
Community health worker model
Care management by nurses
Coaching by peer patients
Telephone coaching
• Care guide model—a blend of these
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What Strategies Work
(literature review)
• Keep costs down
• Support traditional clinic roles and work flows
• Peers > authority figures
• Face-to-face > telephone
• Long-term relationships
• Behavior change theory
Creation of Care Guides
• A new type of non-clinical employee
• Teams with patient, provider and
nurse in clinic
• One task: help chronic disease
patients
• Tool: face-to-face interactions
• Adaptable to different settings,
including small practices
• Low cost
Recruiting Care Guides
• Empathetic, friendly,
outgoing
• Understand limits of
role
• Bilingual when needed
• At least 2 years college
• No experience required
• $16/hour salary
Training (2 weeks)
• Disease basics (HTN, DM, CHF)
• How to shop for inexpensive drugs
• Where to find resources outside clinic
• Electronic health record
• HIPAA, ethics, scope of practice
• Behavior change theory
Essence of a Care Guide
The care guide model supports the triple aim by including a layperson on care delivery teams. The care guide is an
active member of the care team that is easily accessible to patients and providers, builds longitudinal peer
relationships and supports traditional clinic roles at a low cost.
A care guide:
Patient
Focused
A Core
Member of
Care Team
NonHierarchical
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Meets patients face-to-face initially
Shares a patient panel with providers
Provides routine interactions
Shares information
Clarifies questions
Provides motivational coaching
Connects to resources
Documents in patient record
A care guide is not:
Easily
Accessible
Longitudinal
Relationship
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Permitted to give medical advice
Permitted to provide patient referrals
Permitted to distribute patient handouts
without approval
A community health worker
Testing the Care Guide Model
2008
Robina
Care Guide
Project
(Phase I)
2010
•3 Care Guides
•1 primary care
clinic
(Minneapolis)
~ 300 Patients
Robina
Care Guide
Project
(Phase II)
2013
• 12 Care Guides
• 6 diverse
primary care
clinics (urban,
suburban, rural)
> 2100 Patients
Design
• Six primary care clinics (FP/IM)
• Urban/suburban/rural
• Varied use of other care improvement efforts
• One year trial
• 2:1 allocation (intervention: usual care)
• Primary outcome: percent of care goals* met at
1 year
*per JNC-7, ADA and AHA websites
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Results: Patients Working with Care Guides
• 31% more likely than controls to meet
evidence-based goals
• 21% more likely to quit tobacco
• Significant improvement in all diagnosis
groups, across demographic categories
Results: Hospitalizations & ED Visits
Comparing previous year to care guide year, care
guide patients to controls:
• Fewer hospitalizations
• Fewer ED visits
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Perceptions of Care
Care guide patients reported more:
• Social support (P =.013)
• Help (P < .001)
• Individualized care (P =.023)
• Reinforcement (P < .001)
• Understand how to manage illness (P =.004)
• This clinic listens to me, cares about me, I would
recommend it
Care Guides as QI Agents
• Not a monthly report
• Not a pop-up reminder in EHR
• Instead, informal discussions with providers
• On day of appointment
Providers and nurses liked them:
– 93%: care guides improved care
– 94%: an effective use of resources
Care Guide Model Benefits
Cost
Quality
• Low cost
• Salary, benefits: $286/patient/year
• Potentially affordable for smaller
clinics
• Target patients not meeting care goals
• Care guides communicate missing
tests/issues to providers
• Serve as quality improvement agents
rather than a monthly report or popup EHR
Efficiency
Patient Experience
• Care guides can manage ~190
patients
• Allows for clinics to maintain
traditional roles and workflows
• Accepted by nurses and doctors
• Patients saw care guides as peers
rather than authority figures
• Work with patients ready to change
• Relationships built trust and
affection; patients did not want to
disappoint care guides
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Creation of Care COPILOT
2008
Robina
Care Guide
Project
(Phase I)
•3 Care Guides
•1 primary care
clinic
(Minneapolis)
2013
2010
Robina
Care Guide
Project
(Phase II)
• 12 Care Guides
• 6 diverse
primary care
clinics (urban,
suburban, rural)
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Care
COPILOT
•Promote broad
awareness and
adoption of Care
Guide Project
•Promote
development of
variations of
Care Guide role
Next Steps
• For additional information, visit our Care COPILOT website at
www.healthcarecopilot.com
• Contact Care COPILOT directly to start a care guide program at your
organization:
Haley Barton
Care COPILOT, Market Development
haley.barton@allina.com
612-262-5056
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Upcoming RARE Events….
Stay tuned for the next RARE Webinar:
“HIT in Post-acute Care Settings”
Friday March 28, 2014, 12-1pm
Future webinars…
To suggest future topics for this series,
Reducing Avoidable Readmissions
Effectively “RARE” Networking
Webinars, contact Kathy Cummings,
kcummings@icsi.org