Kajsa Nichols-Smith | Wellness Navigators

CENTER FOR INNOVATION
2013 COMMUNITY HEALTH TRANSFORMATION
IMAGE HERE
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
Mayo Clinic #: ______________
Date: __ / __ / __
Time: _________
____ Quitting smoking
____ Questions about mental health
____ Access to healthy food
e environment
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 innovation@mayo.edu
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 Health
What affects
your health?
Your
Life
In the Waiting Room Roomed by the LPN Screener Filled
Out 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
Navigating
Life
Transitions
Addressing
Unrecognized
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.
WEEK
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
x10
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.

volunteered
HOURS
V
V
600 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.”
– Patient, 50 y/o femalevolunteered
10
HOURS
V
V
600 1.5
FTE
volunteered
HOURS
V
V
600 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%
41323 41337 41351 41365 41379 41393
OrangeT
WhiteT
11/2013 3/4/2013 3/25/2013 4/15/2013
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
OrangeTeamOperational
WhiteTeamOperational
Volunteersinclinic
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%)
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
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.
WELL
EMPLOYED
PERSONAL
SAFETY
ABUNDANT
NUTRITION
POORDIET
NUTRITION
NOFOOD/
FOODBANK
UNCERTAIN
FOOD/
FOODSTAMPS
SAFENEIGHBORHOOD
UNSAFE
NEIGHBORHOOD
/
COM
M
UNITYWATCH
DANGEROUS
NEIGHBORHOOD
/
EM
ERGENCY
SERVICES
LIVING WAGE
SOME BENEFITS
NO INCOME
SOURCE
MINIMUM
WAGE
NO BENEFITS
EM
ERGENCY

SPECIALTY CARE
ACTIVELIFESTYLE
ACTIVE
COM
M
UNITY
SETTINGPRIM
ARY
CARE /
COM
M
UNITY
M
EDICINE
HOME
LEARNING
INFORMAL /
ACQUAINTENCE
NETWORKS
NOSHELTER
TEMPORARY
SHELTER
UNCERTAIN
HOME
STABLE
HOME
RIDE SHARE
COM
PLETE
STREETS
COM
M
UNITY
PUBLIC
TRANSIT
PRIVATE
TRANSIT
CAR / BIKE
CLUBS /
FAITH GROUPS
SUPPORT GROUPS
PEER
NETWORKS
FAMILY /
FRIENDSSCHOOL
COMMUNITY
EDUCATION
INFORM
AL
LEARNING
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.
WELL
EMPLOYED
PERSONAL
SAFETY
ABUNDANT
NUTRITION
SAFENEIGHBORHOOD
UNSAFE
NEIGHBORHOOD
/
COM
M
UNITYWATCH
DANGEROUS
NEIGHBORHOOD
/
EM
ERGENCY
SERVICES
LIVING WAGE
SOME BENEFITS
NO INCOME
SOURCE
MINIMUM
WAGE
NO BENEFITS
ACTIVELIFESTYLE
ACTIVE
COM
M
UNITY
SETTING
M
ARY
NITY
HOME
LEARNING
NOSHELTER
TEMPORARY
SHELTER
UNCERTAIN
HOME
STABLE
HOME
PUBLIC
TRANSIT
PRIVATE
TRANSIT
CAR / BIKE
FAMILY /
FRIENDS
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
innovation@mayo.edu

Kajsa Nichols-Smith | Wellness Navigators

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