Care guides help patients follow plans

They build rapport with their patients

Care guides who work with patients at Minneapolis-based Allina Hospitals & Clinics primary care clinics wear business casual clothes and sit in cubicles in the clinic waiting areas, which makes them accessible to the patients who come to see their doctor.

"Patients find the care guides less threatening and more approachable than staff in white coats. Patients know the care guides aren't going to give them a shot or ask them to take off their clothes," says Richard Adair, MD, a primary care physician and principal investigator for the Allina care guide pilot project, which originated at Abbott Northwestern Medicine Clinic in Minneapolis.

Patients are referred to the care guide program by their primary care physician, says Jessica Taghon, a care guide at Allina Medical Clinic in Faribault, MN. "Most of the time, the doctor or nurse walks the patient over after the visit and introduces them," she says.

Care guides work with an average of about 120 patients, Taghon says. They see the patients every time they come to the doctor, and they contact patients by telephone between appointments to make sure things are going well and to answer any questions. They remind them to get their medication refilled and to schedule follow-up appointments. "I'm not a clinical person, so if they have clinical questions, I pass the information on to their doctor," she says.

Financial limitations are the biggest obstacles patients face when it comes to managing their own care, Taghon reports. She works with the patients' insurance companies and local pharmacies to help patients obtain their medication at the lowest possible cost and helps eligible patients apply for medication assistance programs. "Many times patients aren't taking their medication because they can't afford it, or they won't pick up their refill for two weeks until they get paid. When possible, I help them get free samples to tide them over," she says.

When patients have problems getting to the clinic to see their doctor, Taghon helps them find discounted transportation assistance. "Many of these patients don't know what community benefits are available to them. I help them access the resources that can help them overcome barriers to following their treatment plan," she says.

After patients have seen their doctors, they usually stop by to meet with Taghon, who goes over what the doctor told them and emphasizes their treatment plan. "Lack of motivation to follow their treatment plan is a huge barrier for people with chronic illnesses. I provide encouragement and try to figure out the best way to motivate each patient," she says.

Taghon typically spends about 20 minutes with each patient. "I leave it up to the patient. Most of the time, once they start talking, they stay a while," she says. The frequency with which Taghon calls the patients between visits depends on patient preferences and their needs. She calls most patients monthly.

The care guides use the health system's electronic medical records to access the patients' records. When patients are hospitalized, the care guides follow up with them two or three days later, review the hospital discharge summary, talk to them about their treatment plan, and encourage them to make follow up visits with their primary care physician.

"Patients really appreciate it when I call them after they've been discharged from the hospital," Taghon says. "Often they are overwhelmed by all the information they receive at discharge and just want to get home. They find it helpful for me to go over the discharge instructions with them to help them understand."