Care Companion Program (CCP)

• When the doctor said Anup was ready to go home after heart surgery, his parents were grateful it had gone well but overwhelmed by what came next. The nurse transferred Anup’s care to his parents in 5 minutes, leaving them holding a bag of pills and instructions in a language they didn’t understand. They worried that they would struggle to remember these instructions or miss warning signs of a post-surgical infection. Living hundreds of kilometers away from the hospital, they’d be too far to make the journey back if something went wrong.

• Every time someone is uncertain of what to do for their loved one, Anup’s story is repeated. Around the world, family caregivers often assume expanded roles to compensate for overburdened health systems — a reality brought to the forefront during the COVID-19 pandemic – yet are often under-equipped, leaving facilities feeling alone and helpless. 

• At home or in communities as well, people in underserved regions don’t have access to reliable on-demand services to keep their loved ones healthy. 

• Globally, we are on track to face a shortage of almost 18 million health workers by 2030. Staff have little time for non-urgent medical treatment, with care instructions often provided in mere minutes. Additionally, 40 to 80% of critical health and home care information provided to patients is forgotten immediately, and almost half of what is remembered is incorrect. 

• As a result, family members often leave healthcare facilities without life-saving information on how to care for their loved ones at home, leading to complications, readmissions, and preventable illness and death. Every year in South Asia nearly 1.5 million children under five die. Far too many of these deaths can be averted through health practices at home.

• Caring for loved ones is a universal motivation. Billions of caregivers worldwide, 70% of whom are women, help manage diseases, and advocate for their loved ones. However, they often perform these vital tasks without sufficient support from healthcare systems and without the necessary information and tools to prevent suffering and death. This also leads to significant physical and psychological burdens for the caregivers themselves.

• Noora Health knows that family caregivers — given proper recognition and support — can dramatically impact health outcomes, reducing preventable complications, avoidable readmissions and mortality. Noora Health’s Care Companion Program (CCP) empowers and equips families of patients with life-saving skills to care for their loved ones at home, maximizing the positive impact of time already spent by families and healthcare staff. Our model helps provide families with support when they need it most: in the midst of a health event. This reimagination of the role of the caregiver within the health system reduces the power imbalance between patient, caregiver, and provider, as well as reducing preventable complications, readmissions, and even deaths. 

• Noora Health leverages the massive scale of government healthcare systems and the ubiquity of mobile phones. Noora Health trains healthcare staff through Training of Trainers (ToTs) to readily transfer health skills to family caregivers — which they do through training sessions in healthcare settings, halls and waiting rooms where families are visiting their loved ones. After leaving healthcare facilities, families then connect with Noora Health’s mobile-based remote engagement service, which reinforces and supplements the sessions through reminders, educational content and live chat support (two-way communication), typically over WhatsApp and voice messages (IVR). 

• Core to our model is the development of high-quality content and tools that support behavior change, with an intentional focus on user-centered design. For our in-person training sessions, we design different tools (such as flipcharts and videos) and takeaways for the nurses and healthcare staff to use to deliver the sessions. We have programs in Maternal and Newborn Care (MNC), General Medical and Surgical Care (GeMS), Tuberculosis, Cardiology, Oncology and COVID-19.

• For our remote engagement service, we send customized messages through WhatsApp and voice (IVR) which encourage health-seeking behaviors among patients. We also encourage patients to ask us questions through these modalities and have a team of nurses and doctors to support patients and caregivers through this two-way communication platform. We have seen that 95% of the questions we get can be answered from an FAQ bank - and only 5% require any sort of escalation to our clinical team. We are currently exploring ways in which we can reduce the turn-around-time for our remote engagement service and improve our response efficiency to answer more questions through AI-enabled triaging, keyword based prompts, and bespoke, multilingual knowledge banks. We are excited to learn from others in the space and push the boundaries of digital health in the countries we operate in 

• Please see our Care Companion Chronicles on Youtube to hear more about the program from our stakeholders.

• In South Asia, public hospitals treat the highest volumes of patients, serving as a focal point to drive impact at scale. To maximize our reach and provide access to the most marginalized populations, we aim to reach as many public healthcare facilities as we can — including different types of hospitals, specialty institutions, medical colleges and clinics — and to provide them with tools and training to support multiple condition areas. 

• Our programs are delivered through public health systems across India, Bangladesh, and soon Indonesia, which serve communities that often lack access to healthcare resources, including low-income families, rural populations, and marginalized groups such as women and children. These populations may face barriers such as limited transportation, language, and lack of awareness of available healthcare services

• We continue to adapt our model to reach patients where they are at. We’ve designed programs for facilities across all levels of care to reach patients wherever they may have touchpoints with the public health system. According to the WHO, “scaling up primary health care (PHC) interventions across low and middle-income countries could save 60 million lives and increase average life expectancy by 3.7 years by 2030.” We piloted our Care Companion Program (CCP) in primary care settings in Madhya Pradesh and Punjab, and there has been a demand from patients, families and local partners to further refine and expand this model. In 2023, we are looking to further develop and validate a “Clinic” Model for primary health centers and clinics in India - this will include a more digital-forward approach to supporting our trainers, patients, and families.

• At the end of 2021, we gained access to India’s Reproductive and Child Health (RCH) Portal for multiple states. The database covers maternal, adolescent, and child health across the nation. Access to the RCH Portal, which includes phone numbers of individuals who have received care and been registered during pregnancy, enables us to expand our remote engagement service to more individuals outside of the hospital setting. This helps reach mothers who didn't receive in-facility training, as they may have limited engagement with the healthcare system beyond initial enrollment. In 2022, we began acquiring patients through the RCH in a pilot program in Punjab, providing maternal and newborn care information directly to new and expecting mothers registered in the government portal. The RCH portal also gives us access to rich medical information about mothers which lends itself to better customization and timely care.

• The CCP has seen positive outcomes – in a cohort of patients, the CCP reduced post-surgical cardiac complications by 71%, maternal complications by 12%, newborn complications by 16%, newborn readmissions by 56%, and newborn mortality by 18%. For the mobile component of our solution, our teletraining for COVID-19 patients in home isolation found 48% less likelihood of hospitalizations. We also found that teletraining calls to remind families with Special Newborn Care Unit (SNCU) babies for routine vaccinations increased immunization uptake from 65.2% to 88.2%. We continue to prioritize understanding our impact as we scale, and will continue to run studies on our model and its components across condition areas and health settings.

• Noora Health is guided by a human-centered design approach, rooted in listening to and engaging with the needs of patients, families, and nurses to optimize care in an overstretched healthcare system. This needs finding process continues to inform decision making from initial exploration to scaling, balancing input from all stakeholders. Through rigorous design and frequent testing, we are able to effectively access these harder-to-reach populations. As a result, we produce tools, resources, and services that effectively address barriers to accessing care, meeting people where they are - in a facility or at home, using a technology they are already familiar with – mobile phones. 

• From our early pilots, nurses, whose voices aren’t elevated in the health systems where Noora works, guided us on how to better incorporate family caregivers within the system. Often, they would describe how relevant and important this concept was, but how they didn’t have the right tools to address it. Anand Kumar was the first such nurse our team met in a hospital in Bangalore, and he now directs the organization’s overall training infrastructure.

• To ensure that hospital level staff are activated and oriented to the project, Noora Health conducts “district launches,” where a select group of Master Trainers (MTs), predominantly nurses, are selected and mobilized. These MTs, in turn become ambassadors of the program, promoting and facilitating implementation of the program in their own facilities. This approach allows frontline staff to have direct ownership of the program’s performance, and promote program longevity.

• To ensure that patients and caregivers are supported throughout the rest of their journey, our team of Medical Support Executives (MSEs) field questions from caregivers and provide advice on behavior change in different languages. As we develop the remote engagement service, we keep in mind the varied health practices in the settings we work in, and adapt the tone, frequency, and timing of our messages accordingly.

• As we embark on our current journey of rapid expansion, we want to ensure that the many people our program serves — nurses, patients, and caregivers — have a say in its design. To this end, we led with co-creation workshops to expand in Indonesia. This process of localization and customization was especially important as Indonesia’s health system requirements are different from where we’ve previously worked. We brought together public healthcare system stakeholders to understand the roles, training needs, and opportunities for support for healthcare workers in this new setting. 

• Our work has been fueled by collaborations with over 100 partners — governments, developmental organizations, research institutions, community leaders, and NGOs. In India, eight states have adopted our evidence-based program into their health systems, and the national government recently made our Tuberculosis family caregiver model a key initiative to end TB in India. 

• To accelerate development of our digital platforms, we not only partner with key technology partners (Meta, Turn.io, Snowflake), but also proactively facilitate learning and sharing workshops with other social organizations in the space (ARMMAN, Praekelt, Jacaranda Health, and others).

• Since our founding in 2014, we have trained a cumulative 3,560,302 caregivers, representing 2,427,972 patients. The program is available in 461 facilities and implemented on a daily basis by over 6,500 healthcare providers.

• In 2022, we surpassed one million caregivers reached in a single year, training 1,279,974 caregivers across 308 hospitals and 133 clinics. 

• Through our remote engagement service, we have reached out to over 250,000 users so far. 

  • In Q1 2023, we successfully enrolled 29,380 new users onto our remote engagement service  representing about 9% of caregivers who attended our in-hospital CCP session. In Q1, 24% of our newly enrolled users engaged with our messages, responding with at least one message back. Out of these engaged users, 50% engaged by asking a question. 

• Please see our 2022 Annual Report for more information on our reach. 

• We are looking to the Solve community to refine the remote engagement component of our Care Companion Program as we rapidly scale our programs. We are poised for ambitious scale, with agreements with eight Indian states, the Indian national government, the Government of Bangladesh, and one district in Indonesia. We need to continue building out this technology to effectively support our users at scale. 

• We are developing enabling technology throughout the four stages of a user’s journey on  the remote engagement service. We are seeking mentorship on some of the challenges we are facing: 

  • Enrollment: We currently rely on our master trainers (nurses) to advertise the remote engagement service to patients. Patients either call a number or scan a QR code to sign-up – with variations existing for different condition areas, facilities, and states. The enrollment rates vary from 5% to 45% across our various geographies. How might we streamline and standardize our sign-up funnel  so that we can maximize enrollments? 

  • Customization: Post signing up, enrolled users navigate themselves through a set of questions (such as language, modality preference, sub-condition, etc.) to receive more customized messages. Many users don’t follow the steps and end up receiving a generalized campaign. How might we extract information from our  users in order to offer the most relevant messaging? 

  • Engagement: Our engagement rates hover around 30% for enrolled users. We are A/B testing different kinds of messages and calls to action to increase user engagement. How might we better engage with our  users to nudge them towards the highest impact behaviors through our messages? 

  • Response: About 50% of our engaged users end up asking us questions about their health. Currently, we have a team of nurses and doctors that sift through the questions (on a helpdesk software) and respond by referring to an FAQ bank (created over time), occasionally escalating to doctors when the need arises. How might we use AI-enabled workflows and large language models to make our response system efficient and accurate so that we can focus more on higher-risk patients and queries?

• Being in the Solve network and learning from peers, coaches, experts, and other strategic resources as we tackle some of these strategic technology challenges could be critical to our next stage of growth, both for our technological development and for other aspects of our work. 

• Unlike many innovations in the health system that depend on a new HR requirement or costly technology, Noora Health amplifies trusted, existing and untapped resources. We partner with state and national healthcare systems, upskilling the healthcare staff already employed by the system to deliver the program. By integrating the program into the ongoing operations of these facilities and into government health budgets, we design for sustainability and ensure government partners have ownership of the program moving forward. 

• The program is designed with the reality of busy healthcare providers in mind, and instead of adding an additional burden to their schedule, is designed in a way to provide this information efficiently. Countless providers have mentioned how this additional support at the bedside creates a positive, more caring environment. Moreover, it makes the very limited time spent with the clinician more effective - making those precious minutes go further. We use technology that our frontline trainers and patients are already familiar with to drive adoption, including simple interactive paper-based tools. For healthcare workers, we are piloting WhatsApp-based chatbots as a monitoring tool as well as integrating our digital tools in some of the state-backed apps. In some programs where we have to, we are building thin, offline-first apps that keep the user's needs at the center. For patients, our remote engagement service is built to deliver messages on WhatsApp and voice (IVR) – technologies that are widespread and don’t require additional onboarding among our target population. 

• Not only are our programs proven to improve patient outcomes, our evidence shows that every person we train goes on to train between 1 and 3 additional people. This innate human network effect, compounded by our technology platforms, multiplies our impact from families to communities. Many of these communities are isolated from facilities or community health workers, making these trained households even more of a healthcare anchor. 

• In 2023, we are expanding the reach of our programs. Below are country specific goals for 2023: 

  • India

    • Train 3.5 million caregivers across India

    • Focus implementation on high volume, high need facilities

    • Refine model for health and wellness centers (clinic model) for full scale up in Q3 of 2023

  • Bangladesh

    • Train 400,000 caregivers across Bangladesh 

  • New Countries

    • Train 200,000 people across Indonesia and likely Nepal

• In 2023, we are standardizing and packaging our existing condition areas. We will not build new condition areas. Below are condition area goals for 2023:

  • Maternal and Newborn Care (MNC)

    • Define standard model using the different iterations that have been created; package the model for replication 

  • Cardiac Care

    • Define standard model and package for high-volume facilities

  • Tuberculosis (TB) Care

    • Refine model and support direct implementation of the program in at least 3 states, and support Central TB Division in their national scaling efforts

  • General Medical and Surgical (GEMS) Care

    • Gather feedback on existing programs to identify gaps and opportunities for next iteration 

• In 2023, we are putting more effort in developing our digital platforms and services: 

  • Remote engagement service via WhatsApp and voice messages (IVR)

    • Improve enrollment rates, engagement rates, and response rates

  • Health educator platform

    • Streamline monitoring tools and pilot ways to remotely support master trainers

• We will conduct and share research on the work, making sure we continue to bring a high-impact, low-cost intervention to market. 

  • 2023 goals:

    • Report one high impact evaluation

    • Refine tracking and reporting on cost-per patient trained

    • Refine tracking and reporting on government cost-share and handover (i.e. of monitoring) strategy in each state

    • Establish one national/central level partnership in India that supports effective delivery of our above goals and policy integration

• Over the next five years through 2027, we will:

  • Scale up our programs to reach over 25 million caregivers annually across four countries – training over 70 million cumulative caregivers by the end of 2027. 

  • Scale up our remote engagement service so that at least 70% of our annual trained caregivers receive digital messaging support as well.

• At Noora Health, we prioritize understanding our impact as we scale. For our Care Companion Program (CCP), we primarily track reduction in post-discharge complication rates, preventable inpatient readmission rates, and adoption in evidence-based health behaviors. We have demonstrated evidence of behavior change and health impact. Noora’s Care Companion Program has been proven to have behavioral and clinical health impact on families, with results captured in multiple published studies. Along with our research partners at Stanford’s School of Medicine and Harvard’s T.H. Chan School of Public Health, we have been able to demonstrate the following, comparing those trained vs. untrained through the CCP intervention:

• For family caregivers: 

  • An increase in family caregiver readiness, measured by the Caregiver Activation Measure, a standardized tool to assess their knowledge, skills and confidence 

  • A 6x reduction in reported anxiety

• For patients:

  • A 34 to 78% increase in adopting skin-to-skin care for newborns

  • A 16% reduction in post-discharge baby complication rates and a 12% drop in mother complication rates

  • A 71% reduction in complication rates among cardiac surgery patients

  • A 54 to 56% reduction in avoidable readmission rates for newborns

  • A 18% reduction in the rate of newborn mortality and a 13% reduction in the risk of maternal mortality after childbirth within the first month of delivery

• For our remote engagement service component of the CCP, we track sign up rates for patients and caregivers trained in-facility with our CCP; engagement rates, such as number of users who engage “actively” vs “passively,” as determined engagement with the service (i.e. asking questions); and retention and awareness of key health information. Additionally, we track the kind of questions that patients and caregivers ask, so as to more easily group and provide answers to questions on similar topics, as well as developing pathways to escalate high-risk patients. As we continue expanding the service, we will iterate on what we track and report on for this component of our solution. 

• See the impact page of our website for more information. 

• The theory of change is first built for each new condition area. Our evaluation strategy is tied into measuring indicators at each step of our theory of change, taking also into consideration what is feasible to be measured. For example, if we train a group of nurses and health educators to conduct these trainings in the hospitals, we measure their uptake of knowledge before and after the training using a simple pre-post test. The monitoring data helps us understand the uptake and quality of the program.

• In the evaluation for each condition area, we measure the appropriate knowledge and behavior uptake indicators, outcomes indicators like complications and readmissions, and general indicators like patient/ caregiver activation measures, patient/caregiver satisfaction levels as detailed below. 

• Impact evaluations are done for each new condition area, or when we expand into different geographies or any major change is made to the program. These impact evaluations have control groups, and they are typically powered to test the statistical significance of changes in outcomes. We have mainly used a quasi-experimental study design, with a pre-intervention control group from the same setting before the launch of a program and comparing it to a post-intervention group.  We have used intent to treat approaches to minimize selection bias. Analytical methods for outcomes use adjustment for known and unknown confounders.

• We started our Care Companion Program (CCP) in 2012, and supported families only within hospital facilities through paper-based non digital tools. Our usage of technology was limited to multimedia videos. As we saw our target audience embrace technology, especially mobile technology, we grasped the opportunity to introduce digital technology within our CCP 

• We have three key digital technologies within Noora health-

1. The remote engagement service is a free post-discharge mobile-based support service for patients and caregivers to receive stage-base, reinforcing messages and training on healthy caregiving practices through a combination of pre-recorded audio messages (IVR), text messages (SMS/WhatsApp/Facebook), and live training on the phone. We utilize a combination of cloud based voice communication and various multimedia messaging platforms to reach our users.

2. The health educator platform is an application developed for frontline nurses and trainers to record CCP sessions, attendance during these sessions, and access Noora Health’s educational content

3. The dashboard is a web-based dashboard built on top of our data warehouse that is used by CCP managers to monitor the performance of programs across facilities, and by internal teams to iterate on the service

To implement the above, our cloud based voice communication requirements are managed on Exotel, however we are working towards building the flexibility to integrate with versatile vendors in different states. The scheduled messages are orchestrated through TextIt, a scheduling platform that integrates with our WhatsApp business provider (Turn.io) to send messages.  

As we scale to different geographies, condition areas and levels of healthcare systems and modalities, we have identified the need to transition to an integrated data warehouse - Snowflake - to unite this siloed data and execute diverse analytics. Snowflake will be instrumental in setting up security policies for data privacy, and strengthening compliance.

• From physicians, nurses, and health professionals to designers, researchers, and systems architects, Noora Health’s team strives to bring in perspectives from across sectors. Most of our team members are hired and based in the cities and towns where our partnering hospitals are located. Our team speaks a variety of languages, represents different faiths, socioeconomic backgrounds, and lives all over South Asia (not just in metropolitan areas, but also in remote districts). We ensure that by having a team made up of people who are from the same communities as our partner healthcare facilities, our work is better contextualized. 

• Noora Health believes in collective ownership and empowering decision makers at all levels of management. By aligning to core values and a “North Star” mission and vision, decision makers span from Noora’s Co-CEOs (who equally share organizational authority) to senior management and project managers (who are encouraged to drive Noora Health’s work in the way that best serves organizational objectives and beneficiaries). Checks and balances are fostered through a matrix of interdisciplinary project team structures and management forums, where team leaders across functional fields come together in collaboration and consultation with the diversity of perspectives and communities represented by the Noora Health team. 

• When hiring, Noora Health places an equal importance on a candidate's ability to connect to Noora Health’s core values as they do the candidate’s credentials and experience. Noora Health aims to ensure that all staffing and personnel decisions are made equitably, maintaining empathy at the forefront while putting in place checks to ensure that bias and prejudice don’t affect our process. This includes all decisions relating to the provision of training, transfer, promotion, terms of employment or engagement, or dismissal. Noora Health does not tolerate discrimination of any form and has strict policies in place to uphold our values. 

• Target populations: Underserved patients and families residing in under-resourced areas of Low and Middle-Income Countries (LMICs) 

• Doer@Scale: Government

• Payer@Scale: Government

• Current Doer: Noora Health with increasing uptake by government

• Current Payer: Philanthropy with increasing investment by government

• Products / Services: Noora Health’s Care Companion Program (CCP) supplements existing public health programs and focuses on engaging and empowering families of patients with access to health information. The program has been adapted for several condition areas – Maternal & Newborn Care, Cardiology, Oncology, General Medical & Surgical, and COVID-19 Care.

• How We Deliver Our Programs: We deliver our programs in several avenues ranging from highly specialized facilities to primary care clinics and communities. Our main customers are the patients and caregivers who benefit from our personalized approach of equipping them with the knowledge that sufficiently prepares them to care for their loved ones.

  • We collaborate with state and national healthcare systems to integrate CCP into their ongoing operations and budgets. This partnership includes committing specific resources to allocate a portion of their health budget for training logistics and committing staff to deliver our programs. We train nurses to be Master Trainers through a 3-day immersive Training of Trainers (ToT) program. These Master Trainers become local champions of CCP and train additional designated staff within the facility to provide condition-specific, skills-based sessions to family members as they wait for their loved ones in facility wards, halls, or waiting rooms.

  • After leaving healthcare facilities, caregivers are onboarded to our remote engagement services, which reinforces and supplements the skills and information received. This platform provides tailored information at scheduled points in time, including reminders and new content, over WhatsApp and voice messages (IVR). Our team of Medical Support Executives (MSEs) field questions from caregivers and provide advice on behavior change. This approach encourages facility-wide ownership, ensuring the sustainability of the program.

  • To grow beyond our current process and internal capacities, we have partnered with MAMTA-Health Institute for Mother and Child in Himachal Pradesh to test a model where we scale by providing the guidelines, content, and light touch technical support needed for implementing our programs. This new scaling approach is crucial for expanding to more states and geographies quickly, and it will serve as a model for future scaling efforts.

• Why people want our programs:  Our programs target populations with limited access to healthcare facilities, financial resources, and poor health literacy. The Care Companion Program (CCP) has demonstrated improvements in health indicators, such as reduction in post-discharge complication rate, preventable Inpatient readmission rate, and adoption of evidence-based health behaviors, such as skin-to-skin thermal care for Maternal & Newborn Care and surgical wound care for our Cardiac Care programs. Our programs alleviate the strain on caregivers and on the health system, helping prevent avoidable suffering, readmissions, and even deaths.

• Noora Health’s revenue model consists of funding support from a diversity of sources, including foundations, partnering organizations, individuals, and corporate giving. We hope to continue to bring the cost per patient down and increase the portion of the program that is covered by government / health systems (currently at 30%). The cost sharing model allows Noora to eventually step-back from directly overseeing the program, enabling it to become an integrated and sustainable part of the healthcare infrastructure in the state. Philanthropic capital supports us to develop programs in new condition areas and geographies, in addition to researching and testing out different parts of our model and how it might be expanded.

• In the next few years, as we scale and look for opportunities to close our funding gap, we anticipate diversifying revenue streams by approaching foundations, corporate funders, and new individual donors. We are still solidifying our development strategy with corporations and in the new geographies that we scale into. 

• In 2022, we became a TED 2022 Audacious Project and recipient of the 2022 Skoll Foundation Award for Social Innovation. We are proud to now partner with MacKenzie Scott, The Patchwork Collective, CH Foundation (UK), Pivotal Ventures, Rippleworks, Charles and Lynn Schusterman Family Philanthropies, Ballmer Group, Valhalla Foundation, and Skoll Foundation. Together the awards catalyzed over $52M in funding to support our scaling efforts. These gifts were secured toward the end of 2021, however the vast majority of this funding is time-bound for specific years of our growth through 2027. We have a strong community of established donors, such as Mulago Foundation and Jasmine Social Investments, who have supported us for many years and have renewed commitments on an annual or bi-annual basis. As mentioned above, we are developing a robust development strategy to achieve our ambitious goals through 2027 and beyond and close our current fundraising gap.