kajsa nichols-smith | wellness navigators

CENTER FOR INNOVATION2013 COMMUNITY HEALTH TRANSFORMATION

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Wellness Navigators

• 2 • COMMUNITY HEALTH TRANSFORMATION • Mayo Clinic Center for Innovation •

CHT: Wellness Navigators

WELLNESS NAVIGATORS

How can a clinic have an impact beyond the clinic

visit? How can we effectively address the barriers

to good health that exist outside the clinic setting,

where 99% of a patient’s life takes place?

Whether it’s getting transportation to a medical

appointment, having the resilience to stick with

personal wellness goals, or being distracted from

following a doctor’s advice by the challenge of

finding ways to pay the bills – social determinants

of health affect us all.

It is well known that social determinants of health

influence patients’ risk of developing a serious

condition, ability to follow their care plan, and

capacity to affect their own wellbeing. To have

a lasting impact on a patient’s health, we must

address not only medical needs, but also the

non-medical factors that stand as obstacles to

good health.

We were inspired by Health Leads to create Wellness

Navigators, a clinically integrated and volunteer-

provided service designed to accomplish two goals:

1. Connect patients to community and social

service resources, which address social

determinants of health not feasibly addressed

directly by Mayo Clinic.

2. Support patients in setting reasonable goals

around making healthier choices in their

day-to-day lives.

Wellness Navigators optimize clinic resources,

adding to both the patients’ and clinic’s capacities

to address the root causes of disease in the context

of community and home life. By deploying college

student volunteers trained in basic motivational

interviewing and resource-finding skills, the service

offloads time-consuming work from clinical staff and

empowers patients with information and concrete

steps they can take to address the factors affecting

their overall health and wellbeing.

COMMUNITY HEALTH TRANSFORMATION

The Center for Innovation (CFI) is partnering with the Mayo Clinic Health System (MCHS) and Employee and Community Health (ECH) to create, pilot, and implement a population health model that includes:

Guided by the Triple Aim and informed by CFI’s human-centered design approach, these

projects are contributing to Mayo Clinic’s preparations for the radical shift towards pay for value

and accountability for the total cost of care.

Optimized Care Team

A colocated, multi-disciplinary group that

works together to meet the needs of a shared

team patient panel.

Wellness Navigators

A volunteer-provided, clinic-embedded

service that connects patients with resources

to address social determinants of health.

Patient-centered Care Plan

A unified tool for patients, caregivers, and

clinicians to see, make, and act on care

decisions together.

Community Engagement A clinic-based

coordinator facilitates a self-sustaining,

grassroots wellness movement with clinic

and community champions.

Triple Aim:

Improve the health of

the population,enhance the

patient experience and

reduce the per capita

cost of care.

Health Leads is a

non-profit that enables

health care providers

to prescribe basic

resources like food and

heat and refer patients

to those services.

Health Leads recruits

and trains college

students to fill these

prescriptions by working

side by side with

patients. Learn more

at: healthleadsusa.org

• COMMUNITY HEALTH TRANSFORMATION • Mayo Clinic Center for Innovation • 3 •

WELLNESS NAVIGATORS ADDRESS THE NON-MEDICAL NEEDS OF HIGHER TCOC

PATIENTS BY CONNECTING THEM TO COMMUNITY RESOURCES

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Self Pay Commercial Payers Mayo Insured Government Unknown

Wellness Navigator Avg TCOC 3.7X Kasson Avg Kasson Clinic Avg TCOC

Payer Types – subdivided by clinic number


CONTRIBUTIONS TO POPULATION

HEALTH – TRIPLE AIM STRATEGY

Patient experience is the driving force of the

Wellness Navigators program. By demonstrating to

patients that their priorities, medical and non-medical,

align with the clinic’s, Wellness Navigators make

patients feel cared for on a more personal level.

Embedded within the Optimized Care Team, the

Wellness Navigator role can improve staff satisfaction

and utilization by assisting with needs that require

less medical skill and training to address.

Outcomes, especially patient-important outcomes,

can be more comprehensively supported when the

care team is aware of and able to address all of a

patient’s concerns. Studies of health care outcomes

show improvement at a greater rate when care plans

address social determinants of health, such as

financial situation and social support. Having

Wellness Navigators embedded in the daily workflow

of the practice increases the clinic’s capacity to

address these factors and builds patients’ capacity

to manage them.

Total cost of care is reduced when clinics are

able to identify barriers to health and effectively

connect patients with existing community and

government resources. Wellness Navigators

provide this benefit by improving the utilization of

clinic and non-clinic resources to prevent patients’

conditions from worsening or co-morbidities from

developing due to social determinant factors.

“It was a nice to be able to say to the patient, ‘Here’s some resources. And then if you would like, you can talk to somebody who has all the numbers, who can help you with some of your situation,’ and they say, ‘Absolutely.’ That made me feel so good, because then I know that it [the Wellness Navigators service] works.”

— Baldwin Family Medicine LPN

“We talked a lot about exercising; she gave me some ideas and we’ve done them.” Did this improve your overall health? “Yes!”

— Patient asked about working with a Wellness Navigator volunteer

In Q4 2012 and Q1 2013

patients choosing to work

with Wellness Navigators

had an average Total

Cost of Care (TCOC) that

was 3.7 times higher

than the overall Kasson

clinic population. This

indicates that the Wellness

Navigators provide value

by connecting higher TCOC

patients (largely Medicare/

Medicaid) to non-clinic

resources to help address

their non-medical barriers

to health. Follow up analysis

will be done to track ongoing

TCOC for these patients.



How do you feel about your health today?

If you could change one thing in your life right now, what would it be?

personal relationships

physical health

kids and family

Mark below if you’re feeling positive neutral or negative about...

This has been on my mind for a little while...

____ Everyday stress

____ Child care

____ Finding or affording housing

____ Utility/Phone/Internet bills

____ My mood / tiredness / aches & pains

Mayo Clinic #: ______________

Date: __ / __ / __

Time: _________

____ Quitting smoking

____ Questions about mental health

____ Access to healthy food

____ Stressful home environment

____ Transportation

Room #: ________

How do you feel about your overall wellness at this moment in time?

Poor 1 2 3 4 5 Excellent

work and career something else

home life

emotional health

having money for

the things I need

getting around

food and fitness

healthcare and medicines

personal relationships

kids and family

physical health

The screener is the central tool of the

Wellness Navigators service. Developed

through an iterative process, it has

evolved significantly over time and

continues to be refined. The latest

version of this tool and the history of

its development is available by request

by contacting [email protected]

INSIGHTS

UNDERSTANDING CONTEXT: THE COMMUNITY AND PATIENTS

A service that addresses social

determinants is most relevant to patients

when it is based on a strong understanding

of daily life in their community. Clinic staff

from the local area, school administrators, and

community members active in local organizations

provide a foundation for understanding the most

relevant needs and challenges among the different

sectors of a population. Knowing how patients

already interact with the resources in their

community is a foundation for making referrals

and suggestions that are relevant to patients in

their daily lives.

The attitudes, beliefs, and priorities of a

community are best understood by talking

with community members outside of the

clinic context. No one lives every moment of

their day as a patient. Before they are patients,

they are people who live in a community.

Different communities have different norms,

which need to be understood in order to

effectively connect with patients and invite

them to discuss their personal concerns.

INTEGRATING INTO OPERATIONS:

THE CLINIC AND STAFF

Integrating with how the clinic already works

is necessary for relevance and effectiveness.

Understanding the operational context of the clinic

is key. Talking with staff, we discovered that there

was not adequate time to explain a screening tool

to patients during the check in or standard rooming

processes. Knowing this, we designed a self-

explanatory screener that patients complete on

their own before discussing the results with staff.



Harness ways that staff and patients already

interact with each other and put a structure

around it in order to better support wellness. We

observed that patients were likely to speak about

their overall health and wellbeing with the LPN

who roomed them. Taking note of this, we built the

brief, primary screening conversation into this part

of the workflow.

Patients feel most confident and taken care of

when one is specific about the connections and

support offered. The Care Team should be aware of

what services volunteers are trained to provide and

what services are more appropriate for another

team member – pharmacist, social worker, etc.

– to deliver. Develop a scope of services; provide

information and concrete steps.

Your HealthWhat a�ectsyour health?

Your Life

In the Waiting Room Roomed by the LPN Screener FilledOut in Exam Room

Conversation with the Provider Referral to Wellness Navigator

Helping People Create Safe, Achievable Plans

Helping People Stick with their Plan

Connecting to Healthy Activities

Connecting to Preventive Services

Connecting to Support Resources

Resource Awareness

Lack of Insight into Correlations

Mismatch of Patient / Clinic Concerns and Goals

People Self-Censoring Information Perceived as Unimportant

Dissatisfaction with Care

Counseling

Checking in and Encouraging

Checking in and Encouraging

Education (Risks, Action Plan)

Prescribing Medication

Connecting to Programs

Nursing home / Home Health / Treatment Navigation

Navigating Available Resources

Encouraging Healthy Habits

Supporting Emotional Well-being

NavigatingLife Transitions

AddressingUnrecognized Needs

PATIENT NON-ACUTE / NON-MEDICAL CARE NEEDS

Wellness Navigator Pilot at Kasson Clinic

* *

Minimum training or experience to take action to meet the need for most patients

Appropriate role depends on a patient’s complexity

CARE TEAM ROLES TO INCREASE CLINIC’S CAPACITY TO MEET NEEDS

Any Trusted Personnel

Experienced* Non-Licensed

Personnel

Some Health Care Training

& Scope

RN Scope

Social Work or Therapist

Training

NP / MD Scope

Scope of services.

We used the results

from our first weeks

of screening to

categorize the

patient needs that

emerged. From there,

we assessed the

base-line level of

training and expertise

required to deliver a

given service. Some

of those requirements

vary based on the

complexity of the

individual patient.

The conversation around

the wellness screening

tool was integrated

into the existing clinic

workflow. Patients

are familiar with the

rooming staff asking

them questions about

their health problems at

the start of their visit. It

makes sense, then, to

add the questions about

overall health into this

same conversation.

* Experienced Non-Licensed Personnel: Strong ability to connect with people, sensitivity to unarticulated needs, and motivational skills.

• 6 • COMMUNITY HEALTH TRANSFORMATION •


With direction and training, volunteers can build

meaningful, trusted relationships with staff.

ESTABLISHING A WORKFORCE: VOLUNTEERS

Volunteer sources are all around. Look at

where other organizations in the area find

volunteers. Depending on the context of the

community, ads in the local newspaper or

approaching faith-based groups and service clubs

are also options. Undergraduate institutions are full

of bright potential volunteers eager to meaningfully

improve health care. We recruited our volunteers

from nearby University of Minnesota - Rochester.

Good Navigators are good empathizers.

University staff have unique insights into the

personalities and skills of their students. They

can create interest among potential applicants

and focus in on the students who have the

listening skills, empathy, and resiliency to

make great volunteers.

Quantity does not equal quality with

volunteer training. Forcing large amounts of

information into training yields diminishing returns.

Focus on a handful of concrete concepts at a time

to help volunteers understand their tasks, learn

conversation techniques, and gain the resource-

finding knowledge to confidently provide the

Wellness Navigator service to patients.

Successful interaction with patients and

staff requires training. Most student volunteers

do not have prior experience interacting with

clinic staff professionally or with talking to

patients one-on-one. If chosen for their people

skills, they can learn how to comport themselves,

but there will always be a learning curve.

Practicing mock-interactions is an important

component of pre-clinic volunteer training.

Volunteers need structure. Volunteers are

taking on personal responsibility for people’s

lives, perhaps for the first time in their lives.

Clearly defining the roles, tasks, and organization

of their work gives them the brain-space to focus

on their patients.

“Oftentimes it seems like it’s just me and the patient trying to deal with [the non-medical issues impacting their health], so to have people around me who could help those things is a tremendous positive.”

– Primary Care MD



DAY-TO-DAY OPERATIONS

COMMUNICATING WITH PATIENTS IN THE CLINIC

Promotional material and patient-oriented

questions can prime patients to bring up

social determinants of health and quality of

life concerns during their clinic visits. It may

feel unnatural for patients to discuss their everyday

concerns at the doctor’s office. This new service

should introduce the message that health is impacted

by everyday concerns. This can be done with posters

and fliers in the clinic as well as throughout the

Wellness Navigator workflow. This helps invite the

discussion of non-medical issues in the clinic.

Patients who are motivated to engage with

Wellness Navigators are most likely to

benefit from the service. Wellness Navigator

interactions can be productive whether the patient

has many pressing issues or one off-hand

concern. What makes a difference in the effect the

service has on the patient’s health is the patient’s

own desire to engage with the service. Discussion

with care team members helps to capture the

patient’s motivation. Factors like visit type may

help to identify whether a patient would be

amenable to the service as well. For example, if

the patient comes into the clinic with a crippling

migraine, it might be better to call them later rather

than talk to them during their visit. Patients coming

in for less pre-occupying issues, such as rechecks

may be in a better frame of mind to set new goals

or seek support for their greater wellbeing.

An organized work

structure provides

volunteers with clear

tasks during their shift

and maintains a focus

on patient care.

“ It seems like when you go to the doctor they care about one aspect of you; they don’t care about your personal life. It was nice to have someone care for me on an emotion level.”

– Patient, 56 y/o female



BUILDING AWARENESS

AMONG CLINIC STAFF

Optimized Care Team facilitates the

involvement of Wellness Navigators in patient

care. When an integrated team of providers,

nurses, pharmacists, and other professionals bring

their diverse perspectives to a patient’s care, the

team can uncover the bigger picture of a patient’s

health and draw connections between non-medical

and medical needs. When the entire team is aware

of how their work is supported by addressing

non-medical needs, they refer more patients

and the impact of Wellness Navigators expands.

Optimized Care Team’s open, collaborative

approach produces more comprehensive and

coherent patient care while simultaneously

increasing staff satisfaction.

Stay top-of-mind for providers; respond to

patient needs at the point of care. A consistent,

colocated presence amongst the clinic staff provides

a physical, just-in-time reminder that resources are

available. Having volunteers available on-site

throughout the day builds the habit of referring

patients when needs are identified. Point-of-care

referrals facilitate the care team’s ability to make the

most of the patient’s visit, saving them the time and

trouble of scheduling another visit or phone call.

Wellness Navigators can save time and

improve utilization for each clinic role. For

providers, the service offloads time-consuming

responsibilities that don’t utilize the full capabilities

of a doctor or nurse practitioner’s license. For nurses

and care managers, Wellness Navigators represent

the intensive resource-research service that can find

transportation, financial assistance, or the free

glucometer that helps a patient monitor their own

health. For LPNs, identifying needs to refer to the

Wellness Navigators gives them the opportunity to

act on the information they already hear in rooming

conversations.

2 Following training, getting acclimated to the clinic and the role

“ Still getting used to being in clinic – will be more proactive as I learn the ropes.”

3 Getting to know what they don’t know balanced with information overload

“I would like to be more knowledgeable on resources I can provide.”

“I need more training. I am not comfortable being here alone yet…”

5 Getting comfortable and feeling effective

“Today went much better. …I was able to communicate with a patient in-clinic today and that gave me reassurance that I was actually doing something.”

WEEKLY DEVELOPMENT OF AN NAVIGATOR

From training to their last week in clinic, volunteers go through a process of getting comfortable with

the clinic and their role in it. The learning curve is steep, but ultimately, volunteers emerge with a

deeper understanding of patient needs and an enthusiasm for staying engaged with the service.

WE

EK

Optimized Care Team

A colocated, multi-

disciplinary group that

works together to meet

the needs of a shared

team patient panel.



SUPPORTING AND MANAGING

VOLUNTEERS

In-clinic experience is the best training

volunteers can receive. It can take several

weeks for an Navigator to become comfortable

with this role. Thus, on-site supervision by a

Wellness Navigator Coordinator and detailed

tools and instructions are critical to ensure

services provided are high-quality and volunteers

are comfortable working independently with

patients in the clinic.

Transparency, clear expectations, and direct,

personalized feedback empower volunteers

to generate the data necessary to oversee

and evaluate the service. Communicating why

specific data are needed motivates volunteers to

document and collect them thoroughly; metrics that

have a demonstrable value to the volunteer’s patient

care duties are much more likely to be captured.

Providing straightforward instructions for how

metrics should be collected and integrating their

collection with the workflow of a face-to-face clinical

interaction increases the quality of data collected.

Feedback mechanisms – such as to-do lists – help

to keep volunteers accountable for their work.

Volunteers are motivated to stay accountable

when they feel engaged. Volunteers derive their

satisfaction from face-to-face patient interactions

and from feeling like they’re helping people.

When these things are lacking, volunteers can

become disengaged and, in the worst cases,

discontinue their involvement with the service.

Encouraging volunteers to take pride in small

victories and the intent of the program can go a

long way in maintaining a positive attitude and

reliable workforce.

“It’s nice to follow-up with patients that I have, to see that things have worked out or that they want more of my help. The day got better as I saw in-clinic patients - much better.”

– Wellness Navigator Volunteer, Spring 2013

8 Feeling engaged and thinking critically about continuous improvement

“ Good days are when I get to see patients in clinic. It’s nice to follow up with patients that I have to see

that things have worked out or that they want more of my help.”

10 Getting ready to leave and feeling conflicted

“I’m extremely exhausted this week.”

As they near the end of the semester,

volunteers are often ready for a break.

Yet they describe feeling conflicted

because of the bond they now have

with their patients and their clinic.

12 and beyond Staying connected

“I hope this program continues and enhances its impact on the care of our clients. Let me know if there is anything else I can do for you and the Wellness Navigator program in the future.”



20

volunteeredx10

HOURS

V

V600 1.5

FTE

BUILDING A VOLUNTEER CORPS

During the prototype semesters, we recruited

volunteers from University of Minnesota-Rochester,

15 miles from Kasson with faculty interested in

presenting new opportunities to their students. We

selected the number of volunteers we needed to

provide coverage at the clinic without overreaching

our ability to support their work. There was a high

commitment level expected of these volunteers.

OPPORTUNITIES

In seeking to discover a way to effectively address social determinants of health in a clinic setting, we have prototyped the Wellness Navigator service at Mayo Family Clinic Kasson. Our initial findings indicate the positive impacts this service can have for patients and staff as well as opportunities for continued learning and refinement.

Opportunities remain to explore several

additional volunteer sources in the area.

++ Universities that offer degrees in social work.

++ Individuals applying to volunteer at the local

hospital associated with the clinic.

++ Undergraduate or graduate students in

non-health-related programs of study.

++ Kiwanis, Rotary, and similar clubs.

We explored the idea of using local community

members as a volunteer source and found that in a

small, rural community, most of those who had the

time to volunteer had already found other avenues

to do so. However, this might not be the case in

other communities.



20

volunteeredx10

HOURS

V

V600 1.5

FTE

WORKFORCE EFFICACY

Wellness Navigators are a volunteer-

provided, clinic-supported service that

supplied 1.5 FTE of patient care with a

minimal impact on clinic resources during

the Kasson prototype semesters.

The investment in a Wellness Navigator

Coordinator and program expenses

produces the work and clinic support

of more than two full-time employees.

We began with a volunteer corps because this

kind of non-traditional clinic service delivered

by non-licensed personnel is rarely billable in

the current system. However, as we continue

to follow the outcomes of patients who work

with Wellness Navigators, we hope to

demonstrate the value of this role as a

full-time Care Team staff member.

“It was shocking […] when she said she was a volunteer… I didn’t know they were that well informed. […] She knew her stuff.”


“She was great. She listened to what my issues were, and she called back with ideas. She gave me suggestions at the time, then called back a week or so later with more.”


20

volunteeredx10

HOURS

V

V600 1.5

FTE

20

volunteeredx10

HOURS

V

V600 1.5

FTE

Patients have socioeconomic

concerns that physicians and

clinic staff often don’t have the

capacity to fully address.

Volunteers are a way to demonstrate the value

that a non-licensed role can bring to a Care

Team by providing the time and capacity” to

address and follow up on these concerns.



NEEDS IDENTIFIED AND IMPACTED

The Wellness Navigator screener tool and workflow of the pilot were designed to produce

open-ended conversations with patients wherein needs were identified.

Physically inactive ......................... 20%

Adult obesity .................................. 32%

Childhood overweight or obese..... 70%

Fast food restaurants .................... 43%

Adult smoking ................................ 21%

Limited access to healthy foods .... 15%

Below the poverty line ................. 6.5%

People per square mile .................... 46

Children in single-parent

households .................................... 25%

Integrated Team Members

0

2

4

6

8

10

12

14

16

18

Referral Rates by Simplified Role by Week

Provider Wellness Navigators Outreach Care Team Nursing

41281 41295 41309 41323 41337 41351 41365 41379 41393

Ora

ng

e T

eam

Op

era

tio

nal

White T

eam

Op

era

tio

nal

Volu

nte

ers

in c

linic

12/31/2012 1/21/2013 2/11/2013 3/4/2013 3/25/2013 4/15/2013

41288 41302 41316 41330 41344 41358 41372 41386

Wellness Navigator referral reasons

Kasson Clinic patients paneled .................14,494

Wellness Navigator patients ..........................221

(108 fall 2012, 113 spring 2013)

28% Healthy Living Smoking

cessation, stress, weight loss, healthy

activities, exercise programs, social isolation

22% Basic Needs Financial

assistance, commodities, employment,

housing, food, utilities

14% Healthcare Affording medications,

health insurance, appointment no-show, pain

relief, advanced directive planning

10% Independent Living Support / Home Modifications

9% Transportation

7% Family Needs

5% Mental Health

5% Other

Dodge County at a Glance

Population ........................................ 20,087

Data referenced from countyhealthrankings.org

and the Dodge / Steele Community Health

Action Plan 2010-2014 (www.co.dodge.mn.us/

PH_5yearplan.html)



To further investigate the reasons behind referral rates, one could look at:

The number of patients a provider has

in a day compared to the number of

referrals made.

++ Does a full, busy day lead to more

referrals because more help is

welcomed or to fewer referrals

because it’s an extra thought

that gets lost?

++ Does this trend vary by role?

The percentage of individuals within

a given role who make referrals.

++ Did we successfully integrate with each

individual with a given role or did we

just form one or two close personal

relationships?

Referral rates in comparison to the number

of individuals within role.

++ There is a difference in the extent of

integration demonstrated by 2 care

coordinators referring 10 patients vs.

20 residents referring 10 patients.

INTEGRATION’S IMPACT ON EFFICACY

The impact Wellness Navigators have on patient health is strongly influenced by the collective buy-in of

individual clinic members. The more interwoven the work of Navigators and clinic staff becomes, the more

referrals those staff members make.

Integrated Team Members

0

2

4

6

8

10

12

14

16

18

Referral Rates by Simplified Role by Week

Provider Wellness Navigators Outreach Care Team Nursing

41281 41295 41309 41323 41337 41351 41365 41379 41393

Ora

ng

e T

eam

Op

era

tio

nal

Wh

ite T

eam

Op

era

tio

nal

Vo

lunte

ers

in c

linic

12/31/2012 1/21/2013 2/11/2013 3/4/2013 3/25/2013 4/15/2013

41288 41302 41316 41330 41344 41358 41372 41386

Referrals to Wellness Navigators over time

While referrals by various care team roles to the Wellness Navigator service fluctuated from week to week, Wellness

Navigator involvement seemed to increase as integration into the clinic’s daily workflow increased. This can especially

be seen as the Optimized Care Teams became operational.



HIGHEST UTILIZERS SELF-SELECTED TO ADDRESS SOCIAL DETERMINANTS OF HEALTH

One of the more exciting aspects of this program is that it contributes to prevention by using resources

outside the clinic. Supporting population health in such an innovative manner is made possible in part by

the fact that the highest utilizers – the patients with the most immediate need for preventive health

assistance – are the patients who self-select to receive support from Wellness Navigators.

SPRING 2013 WELLNESS NAVIGATOR PATIENTS: NEEDS AMONG THOSE

HOSPITALIZED DURING THE PREVIOUS YEAR

SPRING 2013 WELLNESS NAVIGATOR PATIENTS: TOP 3 NEEDS BY VISIT FREQUENCY

High Utilizers: Hospitalized Patients

The cost of caring for hospitalized patients drives overall TCOC. Comparing hospitalized and non-hospitalized

patients in the Wellness Navigator panel suggest how these high-cost patients may have distinct needs to address.

Specialty care visits in 2012

0 visits: healthy living (33%)

basic needs (24%)

healthcare (14%)

1-3 visits: healthy living (26%)

independent living support (20%)

basic needs (18%)

4+ visits: healthy living (22%)

transportation (18%)


healthcare (14%)

basic needs (14%)

Primary care visits in 2012

0 visits: healthy living (35%)

basic needs (31%)

healthcare (14%)


basic needs (20%)

healthcare (18%)


basic needs (16%)


8+ visits: healthy living (26%)

transportation (22%)


$

$$

$$$

$$$$

$$$$$

Entire Kasson patient panel

Patients screened to work with a Wellness Navigator

0% 5% 10% 15% 20% 25% 30% 35% 40%

Other

Mental Health

Family Needs

Transportation

Independent Living Support

Health Care Support

Basic Needs

Healthy Living

Non-Hospitalized (n = 87)

Hospitalized (n = 26)

High Utilizers: Patients with Frequent Face-to-Face Visits

Patients’ needs changed depending on the frequency of their health care utilization. Although healthy

living needs represented a frequent concern no matter what patients’ utilization was, high utilizers seemed

to have a different subset of needs than low utilizers. Notably, the patients who had the most difficulty

finding transportation were also the patients who were called in most frequently for appointments.



OPPORTUNITIES TO LEARN MORE ABOUT THE IMPACT OF WELLNESS NAVIGATORS

We believe in the importance of demonstrating efficacy. The following are some ways in which

we will continue to gather data.

LONG-TERM EFFECTS

Changes in the total cost of care (TCOC) of

patients seen by Navigators could be quite

revealing over a longer course of time. Looking

at how the clinic uses resources to take care of

these patients, along with changes in the utilization

of resources as patient conditions are improved

and future serious conditions are avoided, could

provide insight into the efficacy of Wellness

Navigators for prevention.

METRICS FOR HEALTH IMPROVEMENT

Positive changes in health outcomes may be seen

over time. The patient-reported outcomes seen

below may be early indicators of positive impact.

As we move forward, we hope to add to our existing

knowledge base by continuing to gather data and

exploring some of the patterns described here.

Reflecting on detailed, long-term data on the impact

of Wellness Navigators on patient outcomes and

TCOC will fuel refinement of the service.

$

$$

$$$

$$$$

$$$$$

Entire Kasson patient panel

Patients screened to work with a Wellness Navigator

0% 5% 10% 15% 20% 25% 30% 35% 40%

Other

Mental Health

Family Needs

Transportation

Independent Living Support

Health Care Support

Basic Needs

Healthy Living

Non-Hospitalized (n = 87)

Hospitalized (n = 26)

PERCENTAGE OF PATIENTS BY TOTAL COST OF CARE

The patients who self-selected to work

with a Wellness Navigator were also some

of the patients with the highest total cost

of care out of the Kasson Clinic patient

panel. Wellness Navigators helped

address the health needs of patients who

needed additional services the most

and did so by providing extra support

and connecting them with community

resources to help address barriers

to good health.

“He asked if he could send me information about interviewing. I had never heard of INDEED.com before he sent me the information. He gave me information about the Post Bulletin, and sent another packet in the mail. It helped me a lot. Because of what he sent, I learned how to give interviews. I just had an interview, I was prepared.”


“Yes, it was very helpful. Sometimes you need some extra help. You would like your doctor to, but they’re so busy. It helps to have some professional provide the guidance along the way.”


These quotes come from patients who were

asked to give feedback on their experience.

In these surveys, patients were also asked if

they would recommend Wellness Navigators

to a friend or family member.

7 out of 7 respondents reported that they

would definitely recommend Wellness

Navigators to a friend or family member.

3 out of 7 respondents reported that they

already had recommended Wellness

Navigators to a friend or family member.



IDENTIFY AND RECRUIT NECESSARY PERSONNEL

Wellness Navigator Coordinator

A dedicated, full-time staff member who is

responsible for recruiting, training, managing, and

advocating for the program. He or she will

supervise all volunteer activity with patients and

facilitate communication between clinic staff and

volunteers. Ideally, this person has experience

serving as a patient advocate and is able to work

with people from diverse backgrounds, from

student volunteers to seasoned healthcare

professionals.

Clinic Champions

These are existing clinic employees who are

invested in the service’s mission and development.

Influential in rallying support around changes in the

clinic, Clinic Champions are trusted by clinic staff

and have the time and energy to provide both direct

and indirect support for the service’s success. In

addition to identifying Clinic Champions, it is

important to engage support from the clinic’s

operational and physician leadership. Ensure the

service aligns with their goals and expectations.

Wellness Navigator Volunteers

A sustainable volunteer source can come from

a variety of places but ultimately provides a

renewable workforce that is motivated to

provide the service you create. Identify partner

organizations, such as nearby colleges and, as with

the clinic, gain support from the organization’s

leadership. Seek out individuals who are passionate

about the partnership; they will be the program’s

champions within that organization.

DIFFUSION



DEFINE THE SCOPE OF SERVICE

Discover what the community wants and needs

1. Assess the community’s needs in key areas like

basic needs, transportation, financial stability,

availability of healthy activities, and access to

health care. While reports may already exist and

provide statistics on community needs, be

aware that such an overview may not reflect

how people behave in their everyday lives.

Conducting one-on-one interviews with

community members and reflecting these

responses against data from resources like

CountyHealthRankings.org is one example of

how both qualitative and quantitative methods

can be combined to yield a nuanced analysis.

2. Survey and catalog the available community

resources and assess how accessible they are

in the community. Groups such as the United

Way, community action councils, or county

caseworkers often have a working knowledge

– if not a published directory – of resources.

State and local governments may also have well

curated resource databases, like MinnesotaHelp.

info, already available for public use.

Develop the service

1. Create an explicit description of

Wellness Navigator service offerings:

++ What needs can be addressed.

++ How they can be addressed.

++ What outcomes are expected

to consider a need “resolved.”

++ What protocols are needed for situations

that are out of a volunteer’s scope, e.g.

domestic violence, abuse.

2. Design a method for capturing the

target population:

++ Screening tool or survey (see Tools p.19).

++ Workflow for how the screening tool or

survey will be used (see Tools p.19).

Identifying community

needs may reveal

opportunities to activate

underutilized roles and

resources – dietitians,

social workers, or

behavioral health

programs – within the

clinic as well as to address

community health goals

through education

and coordination with

Community Engagement.

WELLEMPLOYED

PERSO

NAL

SAFE

TY

ABU

ND

AN

TN

UTRITIO

N

POO

R DIET

NU

TRITION

NO

FOO

D /

FOO

DBA

NK

UN

CERTAIN

FOO

D /

FOO

D STA

MPS

SAFE

NEIGHBORHOOD

UNSAFE

NEIGHBORHOOD /

COMM

UNITY WATC

H

DANGEROUS

NEIGHBORHOOD /

EMER

GENCY

SERVIC

ES

LIVING WAGESOME BENEFITS

NO INCOMESOURCE

MINIMUMWAGENO BENEFITS

EMERGENCY &

SPECIALTY CARE

ACTIVELIFESTYLEACTIVE

COMMUNITY

SETTINGPRIMARYCARE /

COMMUNITY

MEDICINE

HOME

LEARN

ING

INFORMAL / ACQUAINTENCE

NETWORKS

NO

SHELTER

TEMPO

RARY

SHELTER

UN

CERTAIN

HO

ME

STABLE

HO

ME

RIDE SHARE

COMPLETESTREETS

COMMUNITYPUBLICTRANSIT

PRIVATETRANSIT

CAR / BIKE

CLUBS / FAITH GROUPS

SUPPORT GROUPS

PEERNETWORKS

FAMILY / FRIENDSSC

HOOLCOMM

UNITY

EDUCATIO

N

INFO

RMAL

LEARNIN

G

SOCIAL INTERACTION

EDUCATION

SAFETY

SHELTER

FOOD

TRANSPORTATION

HEALTH

FINANCIAL STABILITY

Shades denote different programs/elements

Contributors to Overall

Health. An individual’s

health is affected by much

more than just medical care.WELLEMPLOYED

PERSO

NAL

SAFE

TY

ABU

ND

AN

TN

UTRITIO

N

POO

R DIET

NU

TRITION

NO

FOO

D /

FOO

DBA

NK

UN

CERTAIN

FOO

D /

FOO

D STA

MPS

SAFE

NEIGHBORHOOD

UNSAFE

NEIGHBORHOOD /

COMM

UNITY WATC

H

DANGEROUS

NEIGHBORHOOD /

EMER

GENCY

SERVIC

ES

LIVING WAGESOME BENEFITS

NO INCOMESOURCE

MINIMUMWAGENO BENEFITS

EMERGENCY &

SPECIALTY CARE

ACTIVELIFESTYLEACTIVE

COMMUNITY

SETTINGPRIMARYCARE /

COMMUNITY

MEDICINE

HOME

LEARN

ING

INFORMAL / ACQUAINTENCE

NETWORKS

NO

SHELTER

TEMPO

RARY

SHELTER

UN

CERTAIN

HO

ME

STABLE

HO

ME

RIDE SHARE

COMPLETESTREETS

COMMUNITYPUBLICTRANSIT

PRIVATETRANSIT

CAR / BIKE

CLUBS / FAITH GROUPS

SUPPORT GROUPS

PEERNETWORKS

FAMILY / FRIENDSSC

HOOLCOMM

UNITY

EDUCATIO

N

INFO

RMAL

LEARNIN

G

SOCIAL INTERACTION

EDUCATION

SAFETY

SHELTER

FOOD

TRANSPORTATION

HEALTH

FINANCIAL STABILITY

Shades denote different programs/elements



ENGAGE STAKEHOLDERS IN SUPPORTING THE SERVICE

Goal: Empower clinical staff to take ownership

of this initiative and to see it as a joint effort to

serve our patients in order to improve the health

of the community.

++ Invite staff members to collaborate in the

co-creation of the service by sharing examples

of social determinant factors they’ve seen affect

their patients’ health and wellbeing.

++ Introduce the service as a grassroots

movement, filling a gap in health care identified

by both patients and clinic staff.

++ Provide structured and unstructured avenues

for communication in a welcoming environment:

hold meetings, invite emails, proactively seek

out opportunities for conversation and input.

Goal: Acclimate patients and the community

to how their care experience might be different

from what they had before.

++ Communicate significant changes through

reliable channels that resonate with your

community, e.g. hold a town hall meeting

or send an article through the newspaper.

++ Focus on the short-term and long-term

benefits of the service while being as

transparent as possible.

++ Form partnerships with community

organizations and social services to

prepare them for potentially increased

client traffic referred from the clinic.



DEVELOP AN OPERATIONAL STRUCTURE

FOR A VOLUNTEER WORKFORCE

Staffing models. Volunteers in a clinical setting are

subject to some of the same types of screening as

employees. Developing a straightforward procedure

for required physical exams, TB tests, and IT setup

ensures the volunteer program is sustainable. If

possible, take advantage of existing, affiliated

volunteer structures; hospital volunteer programs

can serve as operational partners and/or models for

processing and introducing volunteers into clinics.

Documentation tools. If it is not possible for

program staff to access the electronic health record,

alternative documentation tools are necessary.

Community and social service agencies may be

using case management tools that allow volunteer

access. If so, gaining access to these increases the

potential for comprehensive care and collaboration

between medical and non-medical care providers in

the community. We were able to use the Pathways

Community Network (www.pcni.org) as our volunteer

case management tool. This was a resource that had

been brought to our community by the United Way

of Olmsted County.

Dedicated space. Like any other staff member,

volunteers will require access to pagers, phones,

computers, stationery, postage, and paper storage

space for smooth operation (see Tools).

COLLABORATING AND BUILDING KNOWLEDGE

CFI is collaborating closely with the Office of Population

Health to support the continued development and broad

diffusion of the Mayo Model of Community Care. We will

continue to learn from our relationship with Health Leads

and through ongoing testing of the Wellness Navigator

model with our clinic partners. As we refine this model

for addressing social determinants, we would welcome

any additional insights gained from clinics pursuing

similar initiatives.

Tools are available to

Mayo Clinic employees

on the CFI’s internal

website or can be

requested by contacting

[email protected]


MC6295-133

kajsa nichols-smith | wellness navigators

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