The Role of Health Coaches in Population Health Lauren Scherer, MS, Medical Home Developer 4/21/2017

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 4/21/2017

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. 4/21/2017

Patient Engagement: The foundation of successful population management 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) 4/21/2017

Current state of Patient Engagement 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 4/21/2017

Patient Engagement Takes Time 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 4/21/2017

The role of health coaching 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 4/21/2017

Delivery system to meet community health needs

What does the role look like? 4/21/2017

What does the role look like? 4/21/2017

The Health Coach Tool Box Motivational Interviewing Shared Goal Setting Teach Back (patient education) Self-Management tools Care Coordination Community resource linkage 4/21/2017

The Health Coach Tool Box: Motivational Interviewing and Shared Goal Setting 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 and role 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. 4/21/2017

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 4/21/2017

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) 4/21/2017

Risk stratification to support health coaching intervention 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. 5% High-Cost Patients 20% Rising-Risk Patients 40% At-Risk Patients 35% Healthy Patients Panel Sizes: Nurse Care Coordinators – 200/FTE Get Fit Get Healthy Wellness Clinicians – 500/FTE Community Wellness & Education – Groups 4/21/2017

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 4/21/2017

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 4/21/2017

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! 4/21/2017

Questions? Thank you! 4/21/2017