Care guides help patients follow plans
Lay health workers staff MD offices
Allina Health, a nonprofit health system of 12 hospitals and 90 clinics in Minnesota and Wisconsin, has found that lay healthcare workers, called care guides, are helping patients with chronic illnesses meet their treatment goals and keep their conditions under control.
With a grant from the Robina Foundation, Allina developed the care guide program and implemented a pilot project in 2008 with about 300 patients being treated at Abbott Northwestern General Medicine Associates clinic.
In 2010, the program expanded to a randomized controlled study of more than 2,100 patients at six additional clinic locations. Results of the pilot showed that after 12 months, patients who were working with care guides were 31% more likely to meet evidence-based care goals and 21% more likely to quit tobacco than patients who were not part of the care guide program.
"This resulted in significant improvement across all diagnostic groups and demographic categories. Patients with care guides had fewer hospitalizations and emergency department visits," says Kim Radel, MHA, director of the Care COPILOT Institute at Allina Health.
After a year, patients working with care guides were more likely to report improved social support, better individualized care, and better understanding of how to manage their illness, Radel adds. She reports that in a post-study survey, 94% of providers and nurses thought that care guides were an effective use of resources.
Now Allina is implementing the program across the healthcare system and has developed the Care COPILOT Institute, which offers resources to help other hospitals and clinic systems develop a care guide program and advance the use of other lay healthcare roles on care delivery teams.
"We knew that a significant portion of patients with chronic illnesses were not meeting their clinical goals. The health system’s physicians often say they weren’t able to spend the time needed to help patients understand and manage their conditions. Using lay persons as part of the care team to help patients understand and follow their treatment plan is an effective use of resources," Radel says.
Patients targeted for the program have heart failure, diabetes, or hypertension and are struggling with following their treatment plan and keeping their condition under control. When patients are identified for the program, their primary care physicians tell them about the program and introduce them to the care guide.
The care guides are located in cubicles in the primary care physician offices and meet with at-risk patients after their doctor visit and follow up by telephone as needed. Patients can call their care guides at any time and don’t need an appointment to see them in the clinic. Patients have their care guide’s telephone number and can call whenever they have questions or concerns. "We wanted them to be easily accessible to patients and to meet with them face-to-face in the clinic," Radel adds.
"The care guides sit with patients and talk about how they can help patients navigate the healthcare system and learn to manage their conditions. They help the patients focus on chronic disease goals based on clinical guidelines, choose which goals they want to start with, and develop strategies on how to meet those goals," Radel says.
The care guides review the treatment plan, talk about why it’s important to follow it, reinforce the education patients have received from their doctor or nurse and answer any questions the patients may have about the physician’s instructions. They talk about why it’s important to meet their goals and have the time to answer any questions the patients may have.
"The care guide acts as a liaison between the care delivery team and the patient. Often, patients don’t remember everything the physician tells them during an office visit. The care guides reinforce what their doctors have told them and help them overcome barriers to adherence," she says.
The care guides cannot offer medical advice, but they need to know enough about the patients’ conditions to help them find appropriate resources in the clinic or the community, she adds. They help patients sign up for medication assistance and other community resources. They help them follow their treatment plan and help them prepare for their next physician appointment by making lists of questions or concerns.
The care guides are good listeners and are trained to talk to patients as peers rather than using medical language, she says. "They build trust and rapport, and often the patients will tell their care guide things they won’t tell their physicians," Radel says.
For instance, one patient with diabetes had been treated by his primary care provider, but after several visits, his blood sugar level wasn’t changing. After the care guide started working with him, the patient revealed that he wasn’t taking his insulin because of his fear of needles. He didn’t tell his provider because he was ashamed and didn’t want to disappoint the physician. The care guide shared the information with the primary care physician, who switched the patient to oral insulin.
"The situation could have snowballed and the patient could have gotten sicker while the physician could have continued to waste time and resources. The care guide was able to uncover the problem and that patient began to get his blood sugar level under control," she says.
Allina’s care guides have at least two years of college and many have four-year degrees. "We don’t require any specific degree and have applicants with degrees in psychology, business, communications, and other fields as well as people who want to go to medical school eventually," she says. They undergo two weeks of full-time training that includes classes on evidence-based care for chronic conditions, motivational coaching, cultural and diversity issues, documenting in the electronic health record, and shadowing doctors and nurses in the clinic.
"We look for people who have the ability to communicate well and form relationships with patients. They are outgoing enough to have conversations with patients and at the same time keep the relationship on a professional level and stay within boundaries," Radel says.
As part of Allina’s initiative to become a Pioneer Accountable Care Organization, the care guides are now included in a team that includes RN case managers, social workers, and pharmacists who work together to manage high-risk patients. The care guides are based in the clinic but work closely with hospital case managers and other team members to follow up with patients after discharge and make sure they see their provider in the clinic on a timely basis.