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Integrating Lay Health Care Workers into the Primary Care Team
From Allina Health, Minneapolis, MN.
Abstract
- Objective: To describe a care model in which lay “care guides” are integrated into the primary care team to help patients with chronic disease and their providers achieve care goals.
- Methods: Care guides are individuals without formal medical training who receive brief training about chronic conditions and behavior change. General activities include educating and encouraging patients to take control of their illness, supporting medication and treatment adherence, and facilitating resolution of barriers to quality care.
- Results: The care guide model can improve care for some patients with chronic disease at low cost. In a randomized trial testing the intervention, patients with care guides achieved more goals than usual care patients at 1 year (odds ratio, 1.31; 95% confidence interval, 1.16–1.47; P < 0.001).
- Conclusion: Lay health care workers with relevant skills and training, located in clinic waiting rooms where they can meet patients and providers face-to-face, can help chronic disease patients and their providers improve the quality of care.
Improving the quality of care for chronic disease patients is an important goal for the US health care system. Almost half of American with chronic disease fail to receive evidence-based care [1–3]. Reasons for this include limited access to the health care delivery system [4,5] and payment systems that undervalue primary care and provide incentives for more but not necessarily better care [6]. Not only is there a need to improve the quality of care among chronic disease patients, but also to recognize the constraints faced by primary care providers (PCPs) and clinic staff in the current health care environment.
One approach for improving care for patients with chronic disease has been care coordination, or management by health care professionals such as nurses and certified medical assistants [7]. These care managers are usually located in primary care medical offices and have some face-to-face contact with both patients and providers in addition to telephone or electronic contact [7,8]. Care management provided by registered nurses can be effective but is expensive, and it is unclear where payment for these services will come from [7,9].
An alternative approach is employing lay health care workers. In the literature lay health care workers have been referred to as promotoras de salud, lay advisors or navigators, and peer coaches [10–12]. Some of these workers are employees while others are part-time volunteers [13,14]. Tasks assigned to these workers are often limited, such as improving access to cancer care [15], teaching self-help techniques [16–18], or goal-setting [19], and are usually focused on a specific disease or problem. Some of workers do have contact with nurses and doctors, but they tend not to work with the primary care team in the day-to-day provision of care [14].
To improve the quality and efficiency of chronic disease care, Allina Health, a large not-for-profit system of hospitals and clinics in Minnesota and western Wisconsin, hired lay “care guides” to help patients and providers achieve care goals and integrated them into the primary care team. In this article, we describe the care guide model we used and tested and discuss adoption considerations.
Role and Responsibilities of a Care Guide
Care guides are individuals without formal medical training whose general activities include:
- fostering a longitudinal relationship to encourage patients to take control of their chronic illness;
- educating patients about the considerable benefits of best practice treatment;
- communicating with patients, families and providers to keep the entire care team, including the PCP, focused on meeting care guidelines;
- supporting medication and treatment adherence;
- identifying and facilitating resolution of barriers to quality care;
- facilitating referrals to extended care team members and introducing patients to appropriate services or resources within the clinic, health system and/or community they live or work in.
How do care guides differ from other personnel used as care managers? Care guides can explain the value of meeting standard goals, but unlike nurses cannot answer clinical questions. Care guides and medical assistants have similar salaries but care guides have higher educational requirements, less clinical training, and no competing duties in clinic. Like community health workers, care guides are culturally similar to the patients they serve, but are located in the clinic. Care guides were recruited for specific traits and competencies: an outgoing personality, the ability to engage easily with people of different ages and backgrounds, and a second language where needed (eg, Spanish and Somali in the pilot study) [20].
Implementation Trial
The study recruited 2135 patients. Both groups had an increased percentage of goals met at the end of the 1-year study compared to baseline. Care guide patients met a larger percentage of possible care goals at 1 year than did usual care patients (odds ratio, 1.31; 95% confidence interval, 1.16–1.47; P < 0.001). Care guide patients reduced unmet goals by 30.1%, usual care patients by 12.6%. The difference in outcomes between the 2 groups was minimally affected by differences in the times of final measurement for each goal. The benefit of working with a care guide was not different across demographic categories of age, sex, race, language, insurance, or education. In this study, care guides helped a broad range of patients who were meeting many goals at baseline and who were cared for by providers already receiving regular quality-improvement feedback. Estimated cost was $286 per patient per year.
Development Process
At each clinic, the research team enlisted the help of a site-specific implementation team consisting of a provider champion and clinic leader (ie, the clinic manager, clinic supervisor, or business office supervisor) to customize the study implementation. After selecting the target patient population, chronic disease focus, and eligibility criteria, the research team solicited the help of providers, nurses, medical assistants, and other clinic support staff to develop care guide workflows and processes. Clinic providers and staff were involved early and often in the model planning process. The team gave thoughtful consideration to existing clinic work processes and personnel dynamics to help ensure that the care guide would be accepted and integrated into the clinic culture.
Concurrent with designing workflows for the interactions between care guides and providers, clinical staff, and patients, the research team worked with a variety of support departments at Allina Health System to ensure that the necessary tools were in place for care guides to do their work effectively. They collaborated with human resources to screen for care guide candidates with appropriate skills and personal attributes; information systems to create new tools and security access within the electronic health record; learning and development to organize resources and devise an appropriate training schedule; and marketing/communications to broadcast this new initiative on a system-wide level.
Once details of the model and workflows were established, the research team secured subject matter experts to build content for care guide training. The research team partnered with PCPs whose expertise was treating these chronic diseases as well as pharmacists, nutritionists, diabetes nurse educators, and behavioral health specialists available within the health system. These subject matter experts provided the training content as well as conducted the training. Training took place over 2 weeks and included basic training on the 3 chronic disease conditions, pharmacology, nutrition, and mental health issues, barriers to care, and behavioral change techniques.
Benefits
What were the key interactions leading to clinical improvements? What made the intervention successful? Care guides described using a variety of techniques to yield clinical improvements. With patients, care guides took time to explain the benefits of meeting goals in lay language, used their non-medical backgrounds to create an environment where patients felt at ease asking questions, called patients following office visits to ensure instructions were understood, and helped develop specific action plans. With providers and nurses, care guides gave reminders about unmet goals on the day of an appointment (when this information would be most useful) and supplied information such as “this patient reports difficulty affording medication” or “this patient seems ready to quit tobacco.” Care guides reinforced the effectiveness of longer-term care relationships; for example, most patients who quit tobacco did so between 9 and 12 months after enrollment in the care guide program. In after-study surveys, care guide patients reported significantly more positive perceptions of their care than usual care patients in constructs measuring social support, individualized care, help, reinforcement, and understanding of how to improve their health.
Care guides, using their relationships with providers, served as quality improvement advocates integrated into the daily process of providing primary care. This arrangement differed from the common practice of giving providers periodic feedback based on data gleaned from the electronic health record.
Moving the quality improvement process into the primary care office resolved many problems related to strictly electronic health record–based feedback. Each patient was considered individually. There was opportunity for conversations about care quality to occur face-to-face; members of the primary care team could discuss when to deviate from a care guideline. Strong relationships and a sense of teamwork increased workplace satisfaction [22]. In a post-study survey of 115 providers and nurses, 93% felt that care guides improved patient care and 94% felt that care guides were an effective use of resources.
Adoption Considerations
Adding a care guide into an existing clinic structure and culture requires planning and customization. In order to fully integrate this role into clinics and on care teams and achieve expected results, 6 steps are recommended:
- Program set-up through recruitment of the proper set of stakeholders to plan for implementation, including logistics, budget, etc.
- Defining details, such as the target patient population and eligibility criteria, how interactions will take place with patients, and the duration of the patient relationship.
- Clinic readiness and program development, including detailed clinic staff orientation and workflow development.
- Clinic-specific development of the care guide training, including enlisting the help of subject matter experts to develop content.
- A 2-week training of newly-hired care guides
- Defining the expectations and job responsibilities of the care guide and proper integration of care guides into care teams.
- Monitoring and evaluation – This is not the last step in the process but rather requires the ongoing work of the clinic staff, providers, and care guides to measure progress and outcomes.
Although transforming care teams in primary care clinics is no easy task, it is the foundation of the care guide model. The premise of the care guide role is simple and relatable, thereby making it transferrable to different patient populations and settings as well as attractive to different types of providers. The model is flexible, allowing room for adaptations while maintaining its focus on serving patients and families and reducing burden for providers and other clinic staff. The model is currently being adapted and used in different settings outside of traditional primary care, including urgent care and emergency departments, specialty services, and patient-centered medical homes, among others. In addition, care guides are being used across different patient populations, including high-risk patients in an accountable care organization, pediatric patients, and patients late in life, to name a few. Each adaptation may have population-specific goals and outcomes, but the core of the model remains focused on the Institute for Healthcare Improvement's triple aim: improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care.
For clinics and care providers interested in integrating care guides within their own clinic, a toolkit, eLearning modules, and evaluation templates, among other resources, are available at no cost through the Care Copilot Institute (www.carecopilotinstitute.org). The Institute was created to translate and disseminate the care guide research.
Conclusion
Lay health care workers with relevant skills and training, located in clinic waiting rooms where they can meet patients and providers face-to-face, can help chronic disease patients and their providers improve the quality of care. Because of its low cost, this model can be implemented in many settings, including small independent primary care offices, where much primary care in the US is still delivered [7,23–25].
Corresponding author: Kim Radel, MHA, Allina Health, Minneapolis, MN, [email protected].
Financial disclosures: Dr. Christianson disclosed that he received grant support from the Robina Foundation.
1. Banerjee D, Stafford R. Lack of improvement in outpatient management of congestive heart failure in the United States Arch Intern Med 2010;16:1–2.
2. Egan BM, Zhao Y, RN A. US trends in prevalence, awareness, treatment, and control of hypertension. JAMA 2010;303:2043–50.
3. McGlynn E, Asch S, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003;348:2635–45.
4. Ghorob A, Bodenheimer T. Sharing the care to improve access to primary care. N Engl J Med 2012;366:1955–7.
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7. Berry-Millett R, Bodenheimer TS. Care management of patients with complex health care needs. Synth Proj Res Synth Rep 2009;(19).
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11. Brownstein JN, Hirsch GR, Rosenthal EL, Rush CH. Community health workers “101” for primary care providers and other stakeholders in health care systems. J Ambul Care Manage 2011;34:210–20.
12. Lewin S, Dick J, Pond P, et al. Lay health workers in primary and community health care. Cochrane Database Syst Rev 2005;(1):CD004015.
13. Doull M, O’Connor A, Welch V, et al. Peer support strategies for improving the health and well-being of individuals with chronic diseases. Cochrane Database Syst Rev 2004;(2):CD004774.
14. Witmer A, Seifer SD, Finocchio L, et al. Community health workers: integral members of the health care work force. Am J Public Health 1995;85(8 Pt 1):1055–8.
15. Steinberg ML, Fremont A, Khan DC, et al. Lay patient navigator program implementation for equal access to cancer care and clinical trials: essential steps and initial challenges. Cancer 2006;107:2669–77.
16. Fu D, Fu H, McGowan P, et al. Implementation and quantitative evaluation of chronic disease self-management programme in Shanghai, China: randomized controlled trial. Bull World Health Organ 2003;81:174–82.
17. Kennedy A, Reeves D, Bower P, et al. The effectiveness and cost effectiveness of a national lay-led self care support programme for patients with long-term conditions: a pragmatic randomised controlled trial. J Epidemiol Comm Health 2007;61:254–61.
18. Rhodes SD, Foley KL, Zometa CS, Bloom FR. Lay health advisor interventions among Hispanics/Latinos: a qualitative systematic review. Am J Prev Med 2007;33:418–27.
19. Heisler M, Spencer M, Forman J, et al. Participants’ assessments of the effects of a community health worker intervention on their diabetes self-management and interactions with healthcare providers. Am J Prev Med 2009;37(6 Suppl 1):S270–9.
20. Adair R, Christianson JB, Wholey DR, et al. Care guides: employing nonclinical laypersons to help primary care teams manage chronic disease. J Ambul Care Manage 2012;35:27–37.
21. Adair R, Wholey DR, Christianson JB, et al. Improving chronic disease care by adding laypersons to the primary care team: a parallel randomized trial. Ann Intern Med 2013;159:176–84.
22. Cassel CK, Jain S. Assessing individual physician performance: does measurement suppress motivation? JAMA 2012;307:2595–6.
23. Nocon RS, Sharma R, Birnberg JM, et al. Association between patient-centered medical home rating and operating cost at federally funded health centers. JAMA 2012;308:60–6.
24. Rittenhouse D, Casalino L. Small and medium-size physician practices use few patient-centered medical home processes. Health Aff 2011;30:1575–84.
25. Fifield J, Forrest DD, Martin-Peele M, et al. A randomized, controlled trial of implementing the patient-centered medical home model in solo and small practices. J Gen Intern Med 2012;28:770–7.
From Allina Health, Minneapolis, MN.
Abstract
- Objective: To describe a care model in which lay “care guides” are integrated into the primary care team to help patients with chronic disease and their providers achieve care goals.
- Methods: Care guides are individuals without formal medical training who receive brief training about chronic conditions and behavior change. General activities include educating and encouraging patients to take control of their illness, supporting medication and treatment adherence, and facilitating resolution of barriers to quality care.
- Results: The care guide model can improve care for some patients with chronic disease at low cost. In a randomized trial testing the intervention, patients with care guides achieved more goals than usual care patients at 1 year (odds ratio, 1.31; 95% confidence interval, 1.16–1.47; P < 0.001).
- Conclusion: Lay health care workers with relevant skills and training, located in clinic waiting rooms where they can meet patients and providers face-to-face, can help chronic disease patients and their providers improve the quality of care.
Improving the quality of care for chronic disease patients is an important goal for the US health care system. Almost half of American with chronic disease fail to receive evidence-based care [1–3]. Reasons for this include limited access to the health care delivery system [4,5] and payment systems that undervalue primary care and provide incentives for more but not necessarily better care [6]. Not only is there a need to improve the quality of care among chronic disease patients, but also to recognize the constraints faced by primary care providers (PCPs) and clinic staff in the current health care environment.
One approach for improving care for patients with chronic disease has been care coordination, or management by health care professionals such as nurses and certified medical assistants [7]. These care managers are usually located in primary care medical offices and have some face-to-face contact with both patients and providers in addition to telephone or electronic contact [7,8]. Care management provided by registered nurses can be effective but is expensive, and it is unclear where payment for these services will come from [7,9].
An alternative approach is employing lay health care workers. In the literature lay health care workers have been referred to as promotoras de salud, lay advisors or navigators, and peer coaches [10–12]. Some of these workers are employees while others are part-time volunteers [13,14]. Tasks assigned to these workers are often limited, such as improving access to cancer care [15], teaching self-help techniques [16–18], or goal-setting [19], and are usually focused on a specific disease or problem. Some of workers do have contact with nurses and doctors, but they tend not to work with the primary care team in the day-to-day provision of care [14].
To improve the quality and efficiency of chronic disease care, Allina Health, a large not-for-profit system of hospitals and clinics in Minnesota and western Wisconsin, hired lay “care guides” to help patients and providers achieve care goals and integrated them into the primary care team. In this article, we describe the care guide model we used and tested and discuss adoption considerations.
Role and Responsibilities of a Care Guide
Care guides are individuals without formal medical training whose general activities include:
- fostering a longitudinal relationship to encourage patients to take control of their chronic illness;
- educating patients about the considerable benefits of best practice treatment;
- communicating with patients, families and providers to keep the entire care team, including the PCP, focused on meeting care guidelines;
- supporting medication and treatment adherence;
- identifying and facilitating resolution of barriers to quality care;
- facilitating referrals to extended care team members and introducing patients to appropriate services or resources within the clinic, health system and/or community they live or work in.
How do care guides differ from other personnel used as care managers? Care guides can explain the value of meeting standard goals, but unlike nurses cannot answer clinical questions. Care guides and medical assistants have similar salaries but care guides have higher educational requirements, less clinical training, and no competing duties in clinic. Like community health workers, care guides are culturally similar to the patients they serve, but are located in the clinic. Care guides were recruited for specific traits and competencies: an outgoing personality, the ability to engage easily with people of different ages and backgrounds, and a second language where needed (eg, Spanish and Somali in the pilot study) [20].
Implementation Trial
The study recruited 2135 patients. Both groups had an increased percentage of goals met at the end of the 1-year study compared to baseline. Care guide patients met a larger percentage of possible care goals at 1 year than did usual care patients (odds ratio, 1.31; 95% confidence interval, 1.16–1.47; P < 0.001). Care guide patients reduced unmet goals by 30.1%, usual care patients by 12.6%. The difference in outcomes between the 2 groups was minimally affected by differences in the times of final measurement for each goal. The benefit of working with a care guide was not different across demographic categories of age, sex, race, language, insurance, or education. In this study, care guides helped a broad range of patients who were meeting many goals at baseline and who were cared for by providers already receiving regular quality-improvement feedback. Estimated cost was $286 per patient per year.
Development Process
At each clinic, the research team enlisted the help of a site-specific implementation team consisting of a provider champion and clinic leader (ie, the clinic manager, clinic supervisor, or business office supervisor) to customize the study implementation. After selecting the target patient population, chronic disease focus, and eligibility criteria, the research team solicited the help of providers, nurses, medical assistants, and other clinic support staff to develop care guide workflows and processes. Clinic providers and staff were involved early and often in the model planning process. The team gave thoughtful consideration to existing clinic work processes and personnel dynamics to help ensure that the care guide would be accepted and integrated into the clinic culture.
Concurrent with designing workflows for the interactions between care guides and providers, clinical staff, and patients, the research team worked with a variety of support departments at Allina Health System to ensure that the necessary tools were in place for care guides to do their work effectively. They collaborated with human resources to screen for care guide candidates with appropriate skills and personal attributes; information systems to create new tools and security access within the electronic health record; learning and development to organize resources and devise an appropriate training schedule; and marketing/communications to broadcast this new initiative on a system-wide level.
Once details of the model and workflows were established, the research team secured subject matter experts to build content for care guide training. The research team partnered with PCPs whose expertise was treating these chronic diseases as well as pharmacists, nutritionists, diabetes nurse educators, and behavioral health specialists available within the health system. These subject matter experts provided the training content as well as conducted the training. Training took place over 2 weeks and included basic training on the 3 chronic disease conditions, pharmacology, nutrition, and mental health issues, barriers to care, and behavioral change techniques.
Benefits
What were the key interactions leading to clinical improvements? What made the intervention successful? Care guides described using a variety of techniques to yield clinical improvements. With patients, care guides took time to explain the benefits of meeting goals in lay language, used their non-medical backgrounds to create an environment where patients felt at ease asking questions, called patients following office visits to ensure instructions were understood, and helped develop specific action plans. With providers and nurses, care guides gave reminders about unmet goals on the day of an appointment (when this information would be most useful) and supplied information such as “this patient reports difficulty affording medication” or “this patient seems ready to quit tobacco.” Care guides reinforced the effectiveness of longer-term care relationships; for example, most patients who quit tobacco did so between 9 and 12 months after enrollment in the care guide program. In after-study surveys, care guide patients reported significantly more positive perceptions of their care than usual care patients in constructs measuring social support, individualized care, help, reinforcement, and understanding of how to improve their health.
Care guides, using their relationships with providers, served as quality improvement advocates integrated into the daily process of providing primary care. This arrangement differed from the common practice of giving providers periodic feedback based on data gleaned from the electronic health record.
Moving the quality improvement process into the primary care office resolved many problems related to strictly electronic health record–based feedback. Each patient was considered individually. There was opportunity for conversations about care quality to occur face-to-face; members of the primary care team could discuss when to deviate from a care guideline. Strong relationships and a sense of teamwork increased workplace satisfaction [22]. In a post-study survey of 115 providers and nurses, 93% felt that care guides improved patient care and 94% felt that care guides were an effective use of resources.
Adoption Considerations
Adding a care guide into an existing clinic structure and culture requires planning and customization. In order to fully integrate this role into clinics and on care teams and achieve expected results, 6 steps are recommended:
- Program set-up through recruitment of the proper set of stakeholders to plan for implementation, including logistics, budget, etc.
- Defining details, such as the target patient population and eligibility criteria, how interactions will take place with patients, and the duration of the patient relationship.
- Clinic readiness and program development, including detailed clinic staff orientation and workflow development.
- Clinic-specific development of the care guide training, including enlisting the help of subject matter experts to develop content.
- A 2-week training of newly-hired care guides
- Defining the expectations and job responsibilities of the care guide and proper integration of care guides into care teams.
- Monitoring and evaluation – This is not the last step in the process but rather requires the ongoing work of the clinic staff, providers, and care guides to measure progress and outcomes.
Although transforming care teams in primary care clinics is no easy task, it is the foundation of the care guide model. The premise of the care guide role is simple and relatable, thereby making it transferrable to different patient populations and settings as well as attractive to different types of providers. The model is flexible, allowing room for adaptations while maintaining its focus on serving patients and families and reducing burden for providers and other clinic staff. The model is currently being adapted and used in different settings outside of traditional primary care, including urgent care and emergency departments, specialty services, and patient-centered medical homes, among others. In addition, care guides are being used across different patient populations, including high-risk patients in an accountable care organization, pediatric patients, and patients late in life, to name a few. Each adaptation may have population-specific goals and outcomes, but the core of the model remains focused on the Institute for Healthcare Improvement's triple aim: improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care.
For clinics and care providers interested in integrating care guides within their own clinic, a toolkit, eLearning modules, and evaluation templates, among other resources, are available at no cost through the Care Copilot Institute (www.carecopilotinstitute.org). The Institute was created to translate and disseminate the care guide research.
Conclusion
Lay health care workers with relevant skills and training, located in clinic waiting rooms where they can meet patients and providers face-to-face, can help chronic disease patients and their providers improve the quality of care. Because of its low cost, this model can be implemented in many settings, including small independent primary care offices, where much primary care in the US is still delivered [7,23–25].
Corresponding author: Kim Radel, MHA, Allina Health, Minneapolis, MN, [email protected].
Financial disclosures: Dr. Christianson disclosed that he received grant support from the Robina Foundation.
From Allina Health, Minneapolis, MN.
Abstract
- Objective: To describe a care model in which lay “care guides” are integrated into the primary care team to help patients with chronic disease and their providers achieve care goals.
- Methods: Care guides are individuals without formal medical training who receive brief training about chronic conditions and behavior change. General activities include educating and encouraging patients to take control of their illness, supporting medication and treatment adherence, and facilitating resolution of barriers to quality care.
- Results: The care guide model can improve care for some patients with chronic disease at low cost. In a randomized trial testing the intervention, patients with care guides achieved more goals than usual care patients at 1 year (odds ratio, 1.31; 95% confidence interval, 1.16–1.47; P < 0.001).
- Conclusion: Lay health care workers with relevant skills and training, located in clinic waiting rooms where they can meet patients and providers face-to-face, can help chronic disease patients and their providers improve the quality of care.
Improving the quality of care for chronic disease patients is an important goal for the US health care system. Almost half of American with chronic disease fail to receive evidence-based care [1–3]. Reasons for this include limited access to the health care delivery system [4,5] and payment systems that undervalue primary care and provide incentives for more but not necessarily better care [6]. Not only is there a need to improve the quality of care among chronic disease patients, but also to recognize the constraints faced by primary care providers (PCPs) and clinic staff in the current health care environment.
One approach for improving care for patients with chronic disease has been care coordination, or management by health care professionals such as nurses and certified medical assistants [7]. These care managers are usually located in primary care medical offices and have some face-to-face contact with both patients and providers in addition to telephone or electronic contact [7,8]. Care management provided by registered nurses can be effective but is expensive, and it is unclear where payment for these services will come from [7,9].
An alternative approach is employing lay health care workers. In the literature lay health care workers have been referred to as promotoras de salud, lay advisors or navigators, and peer coaches [10–12]. Some of these workers are employees while others are part-time volunteers [13,14]. Tasks assigned to these workers are often limited, such as improving access to cancer care [15], teaching self-help techniques [16–18], or goal-setting [19], and are usually focused on a specific disease or problem. Some of workers do have contact with nurses and doctors, but they tend not to work with the primary care team in the day-to-day provision of care [14].
To improve the quality and efficiency of chronic disease care, Allina Health, a large not-for-profit system of hospitals and clinics in Minnesota and western Wisconsin, hired lay “care guides” to help patients and providers achieve care goals and integrated them into the primary care team. In this article, we describe the care guide model we used and tested and discuss adoption considerations.
Role and Responsibilities of a Care Guide
Care guides are individuals without formal medical training whose general activities include:
- fostering a longitudinal relationship to encourage patients to take control of their chronic illness;
- educating patients about the considerable benefits of best practice treatment;
- communicating with patients, families and providers to keep the entire care team, including the PCP, focused on meeting care guidelines;
- supporting medication and treatment adherence;
- identifying and facilitating resolution of barriers to quality care;
- facilitating referrals to extended care team members and introducing patients to appropriate services or resources within the clinic, health system and/or community they live or work in.
How do care guides differ from other personnel used as care managers? Care guides can explain the value of meeting standard goals, but unlike nurses cannot answer clinical questions. Care guides and medical assistants have similar salaries but care guides have higher educational requirements, less clinical training, and no competing duties in clinic. Like community health workers, care guides are culturally similar to the patients they serve, but are located in the clinic. Care guides were recruited for specific traits and competencies: an outgoing personality, the ability to engage easily with people of different ages and backgrounds, and a second language where needed (eg, Spanish and Somali in the pilot study) [20].
Implementation Trial
The study recruited 2135 patients. Both groups had an increased percentage of goals met at the end of the 1-year study compared to baseline. Care guide patients met a larger percentage of possible care goals at 1 year than did usual care patients (odds ratio, 1.31; 95% confidence interval, 1.16–1.47; P < 0.001). Care guide patients reduced unmet goals by 30.1%, usual care patients by 12.6%. The difference in outcomes between the 2 groups was minimally affected by differences in the times of final measurement for each goal. The benefit of working with a care guide was not different across demographic categories of age, sex, race, language, insurance, or education. In this study, care guides helped a broad range of patients who were meeting many goals at baseline and who were cared for by providers already receiving regular quality-improvement feedback. Estimated cost was $286 per patient per year.
Development Process
At each clinic, the research team enlisted the help of a site-specific implementation team consisting of a provider champion and clinic leader (ie, the clinic manager, clinic supervisor, or business office supervisor) to customize the study implementation. After selecting the target patient population, chronic disease focus, and eligibility criteria, the research team solicited the help of providers, nurses, medical assistants, and other clinic support staff to develop care guide workflows and processes. Clinic providers and staff were involved early and often in the model planning process. The team gave thoughtful consideration to existing clinic work processes and personnel dynamics to help ensure that the care guide would be accepted and integrated into the clinic culture.
Concurrent with designing workflows for the interactions between care guides and providers, clinical staff, and patients, the research team worked with a variety of support departments at Allina Health System to ensure that the necessary tools were in place for care guides to do their work effectively. They collaborated with human resources to screen for care guide candidates with appropriate skills and personal attributes; information systems to create new tools and security access within the electronic health record; learning and development to organize resources and devise an appropriate training schedule; and marketing/communications to broadcast this new initiative on a system-wide level.
Once details of the model and workflows were established, the research team secured subject matter experts to build content for care guide training. The research team partnered with PCPs whose expertise was treating these chronic diseases as well as pharmacists, nutritionists, diabetes nurse educators, and behavioral health specialists available within the health system. These subject matter experts provided the training content as well as conducted the training. Training took place over 2 weeks and included basic training on the 3 chronic disease conditions, pharmacology, nutrition, and mental health issues, barriers to care, and behavioral change techniques.
Benefits
What were the key interactions leading to clinical improvements? What made the intervention successful? Care guides described using a variety of techniques to yield clinical improvements. With patients, care guides took time to explain the benefits of meeting goals in lay language, used their non-medical backgrounds to create an environment where patients felt at ease asking questions, called patients following office visits to ensure instructions were understood, and helped develop specific action plans. With providers and nurses, care guides gave reminders about unmet goals on the day of an appointment (when this information would be most useful) and supplied information such as “this patient reports difficulty affording medication” or “this patient seems ready to quit tobacco.” Care guides reinforced the effectiveness of longer-term care relationships; for example, most patients who quit tobacco did so between 9 and 12 months after enrollment in the care guide program. In after-study surveys, care guide patients reported significantly more positive perceptions of their care than usual care patients in constructs measuring social support, individualized care, help, reinforcement, and understanding of how to improve their health.
Care guides, using their relationships with providers, served as quality improvement advocates integrated into the daily process of providing primary care. This arrangement differed from the common practice of giving providers periodic feedback based on data gleaned from the electronic health record.
Moving the quality improvement process into the primary care office resolved many problems related to strictly electronic health record–based feedback. Each patient was considered individually. There was opportunity for conversations about care quality to occur face-to-face; members of the primary care team could discuss when to deviate from a care guideline. Strong relationships and a sense of teamwork increased workplace satisfaction [22]. In a post-study survey of 115 providers and nurses, 93% felt that care guides improved patient care and 94% felt that care guides were an effective use of resources.
Adoption Considerations
Adding a care guide into an existing clinic structure and culture requires planning and customization. In order to fully integrate this role into clinics and on care teams and achieve expected results, 6 steps are recommended:
- Program set-up through recruitment of the proper set of stakeholders to plan for implementation, including logistics, budget, etc.
- Defining details, such as the target patient population and eligibility criteria, how interactions will take place with patients, and the duration of the patient relationship.
- Clinic readiness and program development, including detailed clinic staff orientation and workflow development.
- Clinic-specific development of the care guide training, including enlisting the help of subject matter experts to develop content.
- A 2-week training of newly-hired care guides
- Defining the expectations and job responsibilities of the care guide and proper integration of care guides into care teams.
- Monitoring and evaluation – This is not the last step in the process but rather requires the ongoing work of the clinic staff, providers, and care guides to measure progress and outcomes.
Although transforming care teams in primary care clinics is no easy task, it is the foundation of the care guide model. The premise of the care guide role is simple and relatable, thereby making it transferrable to different patient populations and settings as well as attractive to different types of providers. The model is flexible, allowing room for adaptations while maintaining its focus on serving patients and families and reducing burden for providers and other clinic staff. The model is currently being adapted and used in different settings outside of traditional primary care, including urgent care and emergency departments, specialty services, and patient-centered medical homes, among others. In addition, care guides are being used across different patient populations, including high-risk patients in an accountable care organization, pediatric patients, and patients late in life, to name a few. Each adaptation may have population-specific goals and outcomes, but the core of the model remains focused on the Institute for Healthcare Improvement's triple aim: improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care.
For clinics and care providers interested in integrating care guides within their own clinic, a toolkit, eLearning modules, and evaluation templates, among other resources, are available at no cost through the Care Copilot Institute (www.carecopilotinstitute.org). The Institute was created to translate and disseminate the care guide research.
Conclusion
Lay health care workers with relevant skills and training, located in clinic waiting rooms where they can meet patients and providers face-to-face, can help chronic disease patients and their providers improve the quality of care. Because of its low cost, this model can be implemented in many settings, including small independent primary care offices, where much primary care in the US is still delivered [7,23–25].
Corresponding author: Kim Radel, MHA, Allina Health, Minneapolis, MN, [email protected].
Financial disclosures: Dr. Christianson disclosed that he received grant support from the Robina Foundation.
1. Banerjee D, Stafford R. Lack of improvement in outpatient management of congestive heart failure in the United States Arch Intern Med 2010;16:1–2.
2. Egan BM, Zhao Y, RN A. US trends in prevalence, awareness, treatment, and control of hypertension. JAMA 2010;303:2043–50.
3. McGlynn E, Asch S, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003;348:2635–45.
4. Ghorob A, Bodenheimer T. Sharing the care to improve access to primary care. N Engl J Med 2012;366:1955–7.
5. Schroeder SA. Shattuck Lecture. We can do better - improving the health of the American people. N Engl J Med 2007;357:1221–8.
6. Bazinsky KR, Herrera L, Sharfstein JM. Toward innovative models of health care and financing: matchmaking in Maryland. JAMA 2012;307:1261–2.
7. Berry-Millett R, Bodenheimer TS. Care management of patients with complex health care needs. Synth Proj Res Synth Rep 2009;(19).
8. Peikes D, Chen A, Schore J, Brown R. Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials. JAMA 2009;301:603–18.
9. Ayanian JZ. The elusive quest for quality and cost savings in the Medicare program. JAMA 2009;301:668–70.
10. Babamoto KS, Sey KA, Camilleri AJ, et al. Improving diabetes care and health measures among hispanics using community health workers: results from a randomized controlled trial. Health Educ Behav 2009;36:113–26.
11. Brownstein JN, Hirsch GR, Rosenthal EL, Rush CH. Community health workers “101” for primary care providers and other stakeholders in health care systems. J Ambul Care Manage 2011;34:210–20.
12. Lewin S, Dick J, Pond P, et al. Lay health workers in primary and community health care. Cochrane Database Syst Rev 2005;(1):CD004015.
13. Doull M, O’Connor A, Welch V, et al. Peer support strategies for improving the health and well-being of individuals with chronic diseases. Cochrane Database Syst Rev 2004;(2):CD004774.
14. Witmer A, Seifer SD, Finocchio L, et al. Community health workers: integral members of the health care work force. Am J Public Health 1995;85(8 Pt 1):1055–8.
15. Steinberg ML, Fremont A, Khan DC, et al. Lay patient navigator program implementation for equal access to cancer care and clinical trials: essential steps and initial challenges. Cancer 2006;107:2669–77.
16. Fu D, Fu H, McGowan P, et al. Implementation and quantitative evaluation of chronic disease self-management programme in Shanghai, China: randomized controlled trial. Bull World Health Organ 2003;81:174–82.
17. Kennedy A, Reeves D, Bower P, et al. The effectiveness and cost effectiveness of a national lay-led self care support programme for patients with long-term conditions: a pragmatic randomised controlled trial. J Epidemiol Comm Health 2007;61:254–61.
18. Rhodes SD, Foley KL, Zometa CS, Bloom FR. Lay health advisor interventions among Hispanics/Latinos: a qualitative systematic review. Am J Prev Med 2007;33:418–27.
19. Heisler M, Spencer M, Forman J, et al. Participants’ assessments of the effects of a community health worker intervention on their diabetes self-management and interactions with healthcare providers. Am J Prev Med 2009;37(6 Suppl 1):S270–9.
20. Adair R, Christianson JB, Wholey DR, et al. Care guides: employing nonclinical laypersons to help primary care teams manage chronic disease. J Ambul Care Manage 2012;35:27–37.
21. Adair R, Wholey DR, Christianson JB, et al. Improving chronic disease care by adding laypersons to the primary care team: a parallel randomized trial. Ann Intern Med 2013;159:176–84.
22. Cassel CK, Jain S. Assessing individual physician performance: does measurement suppress motivation? JAMA 2012;307:2595–6.
23. Nocon RS, Sharma R, Birnberg JM, et al. Association between patient-centered medical home rating and operating cost at federally funded health centers. JAMA 2012;308:60–6.
24. Rittenhouse D, Casalino L. Small and medium-size physician practices use few patient-centered medical home processes. Health Aff 2011;30:1575–84.
25. Fifield J, Forrest DD, Martin-Peele M, et al. A randomized, controlled trial of implementing the patient-centered medical home model in solo and small practices. J Gen Intern Med 2012;28:770–7.
1. Banerjee D, Stafford R. Lack of improvement in outpatient management of congestive heart failure in the United States Arch Intern Med 2010;16:1–2.
2. Egan BM, Zhao Y, RN A. US trends in prevalence, awareness, treatment, and control of hypertension. JAMA 2010;303:2043–50.
3. McGlynn E, Asch S, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003;348:2635–45.
4. Ghorob A, Bodenheimer T. Sharing the care to improve access to primary care. N Engl J Med 2012;366:1955–7.
5. Schroeder SA. Shattuck Lecture. We can do better - improving the health of the American people. N Engl J Med 2007;357:1221–8.
6. Bazinsky KR, Herrera L, Sharfstein JM. Toward innovative models of health care and financing: matchmaking in Maryland. JAMA 2012;307:1261–2.
7. Berry-Millett R, Bodenheimer TS. Care management of patients with complex health care needs. Synth Proj Res Synth Rep 2009;(19).
8. Peikes D, Chen A, Schore J, Brown R. Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials. JAMA 2009;301:603–18.
9. Ayanian JZ. The elusive quest for quality and cost savings in the Medicare program. JAMA 2009;301:668–70.
10. Babamoto KS, Sey KA, Camilleri AJ, et al. Improving diabetes care and health measures among hispanics using community health workers: results from a randomized controlled trial. Health Educ Behav 2009;36:113–26.
11. Brownstein JN, Hirsch GR, Rosenthal EL, Rush CH. Community health workers “101” for primary care providers and other stakeholders in health care systems. J Ambul Care Manage 2011;34:210–20.
12. Lewin S, Dick J, Pond P, et al. Lay health workers in primary and community health care. Cochrane Database Syst Rev 2005;(1):CD004015.
13. Doull M, O’Connor A, Welch V, et al. Peer support strategies for improving the health and well-being of individuals with chronic diseases. Cochrane Database Syst Rev 2004;(2):CD004774.
14. Witmer A, Seifer SD, Finocchio L, et al. Community health workers: integral members of the health care work force. Am J Public Health 1995;85(8 Pt 1):1055–8.
15. Steinberg ML, Fremont A, Khan DC, et al. Lay patient navigator program implementation for equal access to cancer care and clinical trials: essential steps and initial challenges. Cancer 2006;107:2669–77.
16. Fu D, Fu H, McGowan P, et al. Implementation and quantitative evaluation of chronic disease self-management programme in Shanghai, China: randomized controlled trial. Bull World Health Organ 2003;81:174–82.
17. Kennedy A, Reeves D, Bower P, et al. The effectiveness and cost effectiveness of a national lay-led self care support programme for patients with long-term conditions: a pragmatic randomised controlled trial. J Epidemiol Comm Health 2007;61:254–61.
18. Rhodes SD, Foley KL, Zometa CS, Bloom FR. Lay health advisor interventions among Hispanics/Latinos: a qualitative systematic review. Am J Prev Med 2007;33:418–27.
19. Heisler M, Spencer M, Forman J, et al. Participants’ assessments of the effects of a community health worker intervention on their diabetes self-management and interactions with healthcare providers. Am J Prev Med 2009;37(6 Suppl 1):S270–9.
20. Adair R, Christianson JB, Wholey DR, et al. Care guides: employing nonclinical laypersons to help primary care teams manage chronic disease. J Ambul Care Manage 2012;35:27–37.
21. Adair R, Wholey DR, Christianson JB, et al. Improving chronic disease care by adding laypersons to the primary care team: a parallel randomized trial. Ann Intern Med 2013;159:176–84.
22. Cassel CK, Jain S. Assessing individual physician performance: does measurement suppress motivation? JAMA 2012;307:2595–6.
23. Nocon RS, Sharma R, Birnberg JM, et al. Association between patient-centered medical home rating and operating cost at federally funded health centers. JAMA 2012;308:60–6.
24. Rittenhouse D, Casalino L. Small and medium-size physician practices use few patient-centered medical home processes. Health Aff 2011;30:1575–84.
25. Fifield J, Forrest DD, Martin-Peele M, et al. A randomized, controlled trial of implementing the patient-centered medical home model in solo and small practices. J Gen Intern Med 2012;28:770–7.