Read about our Excellent Care in three nationally published articles:

"Office-Based Health Coaches: Creating Healthier Communities"

"Mercy Clinics: The Medical Home- Redesigning Primary Care Delivery Systems for Patient Centeredness"

Essential Functions:

• Oversees the disease registry database
• Conducts pre-visit chart review
• Works with patients and families on self-management support
• Coordination of care across the care continuum
• Involvement in QI activities

Coaches Oversee the Registry

• Make sure data is entered into the registry
• Contact patients overdue for visits or not meeting goals (opportunities list)
• In the past only 70% of patients with diabetes came in for a visit within one year
• Review performance report outcomes

Pre-visit chart Review

• Coaches plan the visit
• Health Coaches review the charts of patients before the patient is seen
  —Review for chronic disease standards of care, Preventive health care, immunizations
• Labs and referrals are done before the patient is seen (based on standing orders)
  —More effective than doctor review and frees up doctor time
• Start the diabetes office visit form

Health Behavior Change

• The patient sets the goals for improving health
• Assess
  —Readiness for change
  —Importance of change
  —Confidence of success
• Patient creates a plan for change
  —Identify barriers and plans to overcome them
• Follow-up is done by a time agreed

For more details about Health Coaches, please visit:

• Population Health Coach Job Description
• RN I Population Health Nurse Job Description
• RN II Population Health Nurse Job Description
   

For information about Health Coach certification, please visit:

Physician Office Health Coach Certification Program