1. CCM Health Coaching Integration to Practice Workflows – Traditional Model
Identify Practice Contact for Health Coaching
Recommend Health Coaching to Patients Flagged with Info Sheet
Primary Provider
Review weekly Patient list from Health Coach, confirm for CCM Health Coaching
Practice Contact
Create Practice-specific Patient Coaching Info Sheet and Follow-up Letter
Confirm or establish weekly handoff of Patient list with Practice Contact
ID CCM Health Coaching patients using claims & EMR w/ appts next week
Hand off weekly CCM Health Coaching Patient list to Practice Contact
Flag appts for Provider to reco Health Coaching with Info Sheet
Mail Physician Follow-up Letter and Brochure to Patient
Health Coach
Submit claim to Billing
Document patient’s results & complete Physician report in Cerner tool
Provide ongoing health coaching sessions
Conduct Patient assessment at Patient’s home, schedule next appointment
Make intro call to Patient, gain verbal consent, schedule assessment