indiana university health goshen the role of health coaches in population health lauren scherer, ms,...

Indiana University Health Goshen

The Role of Health Coaches in Population Health Lauren Scherer, MS, Medical Home Developer

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Presentation Objectives

• Explore the relationship of patient engagement to population health management

• Explain the barriers to patient engagement

• Evaluate the role of health coaching within an ACO/Patient Centered Medical Home

• Identify key health coaching tools

• Discuss potential health coaching models


Key terms

• Health Coaching: a process that facilitates behavior change by assisting patients in identifying their own values and motivation to change. Health coaching helps patients gain the knowledge, skills, tools, and confidence to become active participants in their own care.

• Patient Engagement: Development of systems, strategies and communication around patient needs, values and desires so as to empower them to play a central role in their health.

• Population Management: Assuming responsibility for the care delivery, outcomes and cost related to caring for a population of patients.

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Patient Engagement: The foundation of successful population management

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– Reliability Science• Planned Care requires a plan of care developed

by the patient and care team which both believe will work to achieve the set goals

• Patient activation = source of reliability

– Self-Management• Mobilizing patients so that they are capable of

self-care and following through with their care plan

Kabcenell AI, Langley J, Hupke C. Innovations in Planned Care. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2006. (Available on www.IHI.org)


Current state of Patient Engagement

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• 50% of people with hypertension, 62% of people with high cholesterol, 63% of people with diabetes are poorly controlled.Egan et al. JAMA 2010; 303(20):2043-2050, Afonso et al. Am J Manag Care 2006;12:589, Saydah et al. JAMA 2004;291:335

• 50% of patients leave the office visit without understanding what their physician said.

Schillinger et al. Arch Intern Med 2003;163:83


Patient Engagement Takes Time

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• A primary care physician with an panel of 2500 average patients will spend 7.4 hours per day doing recommended preventive care. Yarnall et al. Am J Public Health 2003;93:635

• A primary care physician with an panel of 2500 average patients will spend 10.6 hours per day doing recommended chronic care. Ostbye et al. Annals of Fam Med 2005;3:209


The role of health coaching

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• Patient engager

• Cheer leader

• Patient educator

• Care coordinator

• Leader in QI efforts

• Population management strategist

• Counselor

• Integral member of the primary care team

• The role may be implemented in many ways which is part of what makes the health coach role innovative and unique


What does the role look like?

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Health Coach Role Examples

Patient engagement and self-management support development

•Shared goal setting•Action plan development•Accountability

Support for understanding, motivation, and confidence in the patient’s care plan

•Warm hand-off from provider•Patient education•Health literacy awareness•Use of Motivational Interviewing

Enhance care coordination •Referral tracking•Community resource connection•Discharge follow up


What does the role look like?

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Health Coach Role Examples

Support for delivery of evidence-based care in a team setting

•Development of decision support tools for the team•Pre-visit chart reviews•Identify care gaps

Leader of quality improvement and population management strategies

•Reporting•Project management•Registry management•Leading QI meetings


The Health Coach Tool Box

• Motivational Interviewing

• Shared Goal Setting

• Teach Back (patient education)

• Self-Management tools

• Care Coordination

• Community resource linkage

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The Health Coach Tool Box: Motivational Interviewing and Shared Goal Setting

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• MI is a form of counseling that activates a patient’s own motivation for behavior change

• Outcomes are better when patients take an active interest androle in their own health care.

• Patient = your consultant on their lives and how to best accomplish behavior change

• Goals should be meaningful to the patient

Rollnick, Stephen., Miller, William R., & Butler, Christopher C.. Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York, NY: Guilford Press; 2008.


The Health Coach Tool Box:Patient Education and Self-Management

• Ask the patient’s permission to educate (ask-tell-ask)

• Teach Back: Make patient education a conversation

• Use forms to assist patients in setting goals and forming an action plan

• Use tracking tools (phone apps, web sites, paper logs) to help motivate and encourage accountability

• Increase accountability by checking in soon and often

• Collaborate with pharmaceutical companies to find free resources to meet coaching and education needs

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The Health Coach Tool Box:Care Coordination and Community Resource Linkage

• Identify patient needs and refer appropriately (i.e., mental health)

• Connecting patients to educational opportunities within the community

• Connecting patients to support services within the community (food pantries, council on aging, etc.)

• Connecting patients to support groups (address social support needs)

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Risk stratification to support health coaching intervention

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5%

20%

40%

35%

High-Cost Patients

At-Risk Patients

Rising-Risk Patients

Healthy Patients

Nurse Care Coordinators

Get Fit Get Healthy

Wellness Clinicians

Community Wellness and

Education

•Face to Face Visits•Phone Encounters•Care Coordination•Referrals to Community Resources•Fill Care Giver Gaps

•Goal Setting•Patient Engagement•On-going monitoring of patient progress

•Community Health Needs Group Education and Activities

Note: Health Coaches at Shipshewana and Lincoln Ave support full range of risk.

Panel Sizes: Nurse Care Coordinators – 200/FTEGet Fit Get Healthy Wellness Clinicians – 500/FTECommunity Wellness & Education – Groups


Health Coaching Models to Support Population Management

• Embedded Health Coach

• Centralized health coaching

• Quasi-embedded

• Incorporate health coaching/brief action planning into current workflow/using current staff

• Peer Coaches

• Worksite wellness/coaching

• High risk Nurse Care Coordinators

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Challenges to implementing a health coaching model

• Acceptance by the medical home team

• Training existing staff (time, assessing competency)

• Establishing trust

• Understanding the role/importance

• Pulling into clinical duties (if separate role)

• Establishing a focus (so much to do, so little time!)

• Flexibility within the role/workflow

• Lack of IT interoperability/EHR support

• Proving value

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Practice Recommendations

• Work to create a practice/organizational culture that is focused on continuous quality improvement and patient engagement.

• Find creative ways to incorporate health coaching activities, even if you can’t hire additional staff.

• Make patient engagement and self-management support development a task of all team members-it takes everyone to make a major impact!

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Questions?

Thank you!

indiana university health goshen the role of health coaches in population health lauren scherer, ms,...

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