Team Care For Chronic Disease Patients: Using Lay “Care Guides” Allina Health Friday February 21, – 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 :

Team-based Care Models 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 5

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 A care guide: 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: Permitted to give medical advice Permitted to provide patient referrals Permitted to distribute patient handouts without approval A community health worker Patient Focused Non- Hierarchical Longitudinal Relationship Easily Accessible A Core Member of Care Team 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.

Testing the Care Guide Model 11 3 Care Guides 1 primary care clinic (Minneapolis) Robina Care Guide Project (Phase I) 12 Care Guides 6 diverse primary care clinics (urban, suburban, rural) Robina Care Guide Project (Phase II) ~ 300 Patients > 2100 Patients *per JNC-7, ADA and AHA websites 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

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 13

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 Low cost Salary, benefits: $286/patient/year Potentially affordable for smaller clinics Efficiency Care guides can manage ~190 patients Allows for clinics to maintain traditional roles and workflows Accepted by nurses and doctors Patient Experience 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 Quality 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 pop- up EHR 16

Creation of Care COPILOT 3 Care Guides 1 primary care clinic (Minneapolis) Robina Care Guide Project (Phase I) 12 Care Guides 6 diverse primary care clinics (urban, suburban, rural) Robina Care Guide Project (Phase II) Promote broad awareness and adoption of Care Guide Project Promote development of variations of Care Guide role Care COPILOT

Next Steps 18 For additional information, visit our Care COPILOT website at Contact Care COPILOT directly to start a care guide program at your organization: Haley Barton Care COPILOT, Market Development

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,