To be fully engaged in providing Quality/No Harm, Customer Experience, and Stewardship by:
encouraging self-management and direct communication between the patient/caregiver and the primary care provider; the coach also empowers the patient/caregiver to assert a more active role during care transitions and to develop lasting self-management skills. This will include using patient facing self-management technology to connect with the patients. The health coach will engage patients, and community members in identifying lifestyle modification opportunities, establishing goals and action plans, and conducting follow-up to support healthy, sustainable behavior change The Health Coach will be responsible for contacting patients that are eligible for the program for enrollment and providing necessary wellness coaching to reduce or eliminate high-risk behaviors, improve self-management of their chronic condition, reduce the risk of admission or readmission into the hospital and improve overall health and well-being of the patient. The Health coach will support individual patients with complex needs over a designated period that will include hospital and possible home visits and follow-up phone calls, emails, in order to decrease and/or prevent hospital admissions/readmissions and improve quality of life.
Works with care teams and technology to identify high-risk, high-need patients by helping to implement best practice processes for preventative services, chronic care and disease management
Act as the liaison between the patient, the patient support network, treating physician(s), and ancillary providers utilizing a multi-disciplinary approach to assess, identify, plan, health goal setting and measure optimal clinical outcomes
Provide face-to-face and/or telephonic coaching, support and education.
Utilize motivational interviewing and engagement strategies to support overall health, wellness of patients and self-management which includes employing behavior change/motivational interviewing skills to assess readiness, health goal setting short and/or long term needs, engage patient's plans for change following standard policy and procedures, clinical guidelines and national evidenced-based criteria
Educate and refer patients to available health resources when appropriate.
Provide support to patients in order to help them identify a need for behavior change to improve health status, reduce health risks and improve quality of life.
Follow up with patients to ensure that patient engagement has been achieved and assess future educational and/or program referral needs.
Implements coaching plan by using behavior change principles to identify member barriers and develop ways to overcome those barriers.
Document interactions and interventions as directed with health technology tools.
Support clinical integration and collaboration on patients’ care plan in conjunction with other health professionals
Provides health coaching activities across the continuum of care in order to facilitate and promote high quality, cost-effective outcomes, focused on the whole patient orientation and self- management decision support and aims to minimize any fragmentation of health care delivery.
Supports system-wide efforts pertaining to alternative payment models and reductions in Medicare Spending (MSPB)
Identify cost savings options for patients
Addresses/resolves system problems impeding diagnostic or treatment progress.
Proactively identifies resolves or escalates delays and obstacles.
Demonstrates understanding of level of care criteria and reimbursement factors for home care, rehabilitation, outpatient treatment, residential treatment and long term care in development of discharge plans. Seeks alternatives to discharge planning, and creates relationships with all supportive organization to help in the discharge process.
Demonstrates positive customer relations in all settings and circumstances.
Demonstrates strong I-CARE values
Possess strong empathy skills and able to develop strong rapport with patients
Demonstrates effective communication with other members of the healthcare team and promotes effective team functioning.
Provides patient, family, and/or caregiver education as directed by the plan of care.
Provides service to patients and families with sensitivity and respect for their needs, expectations, age, cultural, and individual differences.
Works with the physician advisor, physicians, nursing, ambulatory programs, outpatient programs, interdisciplinary team and health plan for defined patient populations to develop clinical appropriate transitional pathways, continuum care management for patient care and patient satisfaction.
Coordinates/facilitates patient care progression. Review discharge needs at time of admission, and assists with the transition of care through hospital say and discharge
Works collaboratively and maintains active communication with physicians, nursing, physician advisor, and other members of the interdisciplinary care team to effect timely, appropriate patient resource management, and patient transition.
Seeks consultation from appropriate disciplines/ancillary departments as required to expedite care and facilitate patient transition.
Demonstrates positive customer relations in all settings and circumstances.
Promotes patient's independence by establishing patient care goals; teaching and counseling patient, friends, and family and reinforcing their understanding of disease, medications, and self-care skills.
Provides information to patients and health care team by answering questions and requests.
Resolves patient needs by utilizing multidisciplinary team strategies.
Promotes and restores patients' health by developing day-to-day management and long-term planning of the patient's self care.
Directing and developing staff; collaborating with physicians and multidisciplinary professional staff.
- A Bachelor's degree or higher in health related field (i.e. health promotion, public health, nutrition, kinesiology, exercise science, nursing, etc.)
- Advanced certification - health coaching certification by a NCCA accredited organization, or Wellcoaches® coaching certification is preferred, but not required
- Community education and public speaking experience
- Highly trained and skilled in Motivational interviewing
- Conceptual and applied expertise in chronic and patient-centered care models; experience with managed care models and community health programs strongly preferred
- Knowledge of managed care concepts, health promotion/disease management strategies, and trans theoretical model
- Knowledge of general healthcare practices, office workflows and medical terminology
- Ability to develop health education materials and tailor information at the appropriate level of literacy
- Strong verbal and written communication skills and ability to apply motivational interviewing techniques
- Strong organizational and prioritization skills
- Experience conducting educational and support groups
- Knowledge of specific disease and lifestyle related topics such as weight management, tobacco cessation, chronic conditions (CHF, diabetes, COPD) and stress management.
- Knowledge of community health and social service agencies and additional community resources
- Positive role model in demonstrating healthy behaviors.
- Working knowledge of wellness programming and individual engagement strategies.
- Thorough knowledge and understanding of behavior change theories and their application.
- Strong proficiency in Windows-based database applications
- Ability to work independently and prioritize a heavy workload with minimal supervision
- Ability to work with patients to develop health enhancement strategies to improve health outcomes and self-management
- Exceptional problem solving skills and adept at conflict resolution
- Strong customer service skills and ability to function among a high performing team
- Ability to communicate in a timely manner with all stakeholders
- Ability to effectively establish rapport with patients/members in person and via telephone