The Health Coach: An Asset for a Provider’s Practice
Posted by Cathy Curley, PhD, RN and Maxwell Kursh, MS on June 22, 2018
Two part series on Care Coordination Team: part one on Population Care Coordinators was previously published on October 12, 2017. The second part of the series are the health coaches.
We are often asked, “how do health coaches manage their patients?” Thanks to a robust data analytics department, we have a variety of tools in place to track, manage and evaluate the healthcare status of our patient panels. In particular, we follow the “rising-risk” ACO patients. Based upon the Institute for Healthcare Improvement’s model, rising risk patient are those with two or more chronic conditions and one to two emergency department or inpatient admissions within the past 90 days. The health coach is a member of the care coordination team whose role is to provide education, support and navigation for patients to self-manage their conditions to maintain and improve their health.
A daily hospital discharge report provides context for patient demographic information, admission date and length of stay. Within 24-48 hours, we call the patient to address any cause for readmission and to ensure a smooth transition home. Our primary focus is to address barriers like discharge instruction discrepancies, transportation, medication obstacles, gaps in care and food insecurities. A hospital follow-up visit is also scheduled with their primary care provider within 7 days during this time. We engage with these patients in person, on the phone and electronically via myCooper for 30 days to prevent a readmission.
By establishing a relationship early, we support our patients along their health care journey and offer guidance each step of the way to address their ongoing needs. Techniques like motivational interviewing and brief action planning empower our patients and help promote self-management of their conditions as well as close gaps in care (e.g. health maintenance). These strategies serve as a good follow-up for their visit to reinforce behavior change concepts and make their next office visit more effective.
So, how do we connect, promote and leverage health coaches in the primary care setting to ensure future success? Providers can be our biggest champion! We encourage and request you refer patients either in person or by way of caretransitions@cooperhealth.edu. We look forward to working with you and your patients.
