Our CIN/ACO Health Coaching efforts focus on high cost, high risk, attributed patients, a small percentage of your overall patient population. Each Health Coach, RN receives a list of risk stratified patients to reach out to and to add to their care team. Therefore, not all CIN/ACO patients will fall under the care of a Health Coach. The expected care team of each Health Coach, RN is approximately 80-100 patients.
- The Health Coach engages with high risk, attributed patients telephonically for care management.
- The Health Coach initiates the collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes.
- The Health Coach helps patients gain the knowledge, skills, tools and confidence to become active participants in their care so that they can reach their self-identified health goals.
- The Health Coach ensures that the patients are aware of Red Flag Symptoms specific to their disease process, reviews medications and ensures that the patients are knowledgeable about the medications that they take, and supports the patient in identifying and reaching their personal goals.
- The Health Coach will notify you or your office with any identified change in condition or if they identify that the patient is not following your prescribed plan.
- The Health Coach will also notify you of a positive Depression, Anxiety, or Fall Screen.
- If the Health Coach identifies a resource need that requires a Physician order (such as home health care) you will receive a flag/alert containing the details.
The Health Coach does not interfere with your patient care, practice clinical medicine, direct patient care, or provide treatments or medications.