Reports From the Field

Integrating Lay Health Care Workers into the Primary Care Team

Journal of Clinical Outcomes Management. 2014 December;21(12)

Author(s):

Kim Radel, MHA

Sochenda Te Nelson

Melissa Hutchison, MPH

Jon Christianson, PhD

Heather Britt, MPH, PhD

References

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.

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.