Health Coach

POSITION SUMMARY  

Health Coaches are an additional member the integrated care team for our patients in primary care. Health Coaches work with patients to improve the health condition for those with specified chronic disease conditions. Principally, the Health Coach helps the patient develop and adhere to self-management goals, serves as the connection to the clinic for the patient between visits, assess barriers to success, namely paying close attention to social determinants of health, and encouraging patients to follow up with their care. Health Coaches also provide improve health literacy for patients by providing one-on-one and/or group health education. This position is a part of the Delivery System Reform Incentive Payment (DSRIP) program that strives to improve clinical outcomes in the effort of reducing avoidable hospitalization and emergency department usage.

ESSENTIAL FUNCTIONS

1. Identifies patient’s self-management goals as a part of their overall care plan to improve chronic disease state.
2. Provide education on patient’s health condition(s) to improve health literacy
3. Conduct health education groups for patients with chronic conditions
4. Supports care coordination, assists with referral management, conducts between-visit outreach & contact, and reports all findings to care team members
5. Reinforces education provided by PCP or nurse on management of the chronic disease, provides self-management tools, and reviews how to use those tools
6. Maintains contact with patient to evaluate patient progress and encourage adherence to treatment plan and self-management goal.
7. Reminds patient and caregivers to complete other post-visit tasks, such as lab testing, radiology studies, and specialty visits if needed
8. Uses registries to identify patients with newly diagnosed and/or poorly controlled chronic for but not limited cardiovascular disease conditions, asthma, other chronic conditions, palliative care needs, and depression.
9. Serves as a key primary care practice’s contact during post-discharge care transition from transitional care managers and other hospital or emergency department staff members
10. Documents activities, including self-management goals/updates in eClinical Works
11. Assists in achieving Delivery System Reform Incentive Payment (DSRIP) deliverables
12. Coordinates with Health Home case management for eligible and enrolled patients
13. Evaluates barriers patients experience to successfully engage in care, paying particular attention to social determinants of health.
14. Provide patients with appointment reminders, follow-up calls between visits, and outreach for those patients who miss appointments for those who are in panel.

EDUCATION/EXPERIENCE:

Minimum bachelor’s degree in a relevant field preferred, and one year’s experience in social services required.