Team Care For Chronic Disease Patients: Using Lay “Care Guides”

Team Care For Chronic Disease Patients: Using Lay “Care Guides”

Allina HealthFriday February 21, 2014

1 – 2 p.m. CST

RARE WebinarTeam 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

• 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

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

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

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2008 2010 2013

~ 300 Patients > 2100 Patients

*per JNC-7, ADA and AHA websites

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

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Creation of Care COPILOT

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2008 2010 2013

Next Steps

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• 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.com612-262-5056

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