Health Coach Competencies
§ Gather essential and accurate information about patients in target population.
§ Communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and families.
§ Make informed decisions on care management approach to goal setting based on patient information and preferences, communication and partnership with providers, and evaluation of patient clinical data.
§ Develop and carry out, and document patient self-management plans.
§ Counsel and educate patients and their families.
§ Use information technology to support patient care decisions and patient education.
§ Perform competently all activities considered essential for the area of practice.
§ Provide health care management services aimed at reducing disease complications, preventing health problems or maintaining health.
§ Work effectively with all health care professionals, including those from other disciplines, to provide patient-focused care.
§ Know how to access resources available within and external to of the medical home.
Health Coach Overview
Goals:
Participants will articulate the role of health coaches to the primary care setting and be prepared to apply learned principles to their scope of practice. Health coaches are expected to:
1. Provide care management of patients with chronic illness including diabetes, hypertension, hyperlipidemia, asthma, and chronic pain.
2. Participate actively in sharing of information and ideas with patients, providers, and other members of the health team.
3. Demonstrate knowledge and skills in areas of prevention and chronic disease management and be able to provide this education to patients.
4. Perform assessments and identify patient needs on an individual basis.
5. Provide ongoing communication to providers and patients regarding patients needs and progress.
6. Document all patient care activities and perform data analysis of the population’s progress on a monthly basis.
Objectives:
1. Participants will demonstrate knowledge of key concepts learned through participant feedback, case examples, and scoring at least 80% on final test.
2. Each participant will be able to list the indications for health coaching in the patient centered medical home.
3. Participants will be able to describe evidence based practices within the primary care setting: Community-Based Medical Home, Patient Centered Care, and Chronic Care Model.
4. Participants will know the history and evolution of patient navigation concept, care management, and health coaching and be able to identify similar programs.
5. Participants will be familiar with practices and policies specific to the primary care center: Human Resources, HIPAA, Customer Service, Standards of Care, Care Transitions, Insurance Care Management, Risk Management, and Program Outcome and Quality Reports.
Knowledge of Chronic Conditions
Goal:
Care Managers must demonstrate competence in the knowledge of chronic conditions, implications to care in the community-based medical home, as well as the application of this knowledge to the identification and self-care management planning of patients with chronic disease.
Objectives:
1. Participants will describe basic health promotion, prevention, and risk factors for disease.
a) Nutrition
b) Exercise
c) Risk factors (genetic, environmental, lifestyle)
d) Screening
e) Early detection and intervention
2. Participants will demonstrate knowledge of chronic conditions and the application of this knowledge to patient support and planning in the community-based medical home.
Targeted chronic conditions-
f) Diabetes
g) Hypertension
h) Hyperlipidemia
i) Heart Disease
j) Asthma
k) Pulmonary Disease
l) Obesity
m) Depression
n) Chronic Pain
Patient Care Management
Goals:
1. Health coaches must be able to provide meaningful patient support and education on self-management of chronic disease that is compassionate, culturally appropriate, and effective. Skills and interventions will be based upon evidenced-based proven models and best practices for chronic care models in the community medical home.
2. Health coaches will demonstrate respect and compassion for others, manage conflict, and behave in a manner consistent with the policies of the health center.
3. Health coaches will act in an ethical fashion with sensitivity toward to differences between themselves and their colleagues and patients.
Objectives:
1. Obtain comprehensive needs and barriers assessment based upon learned models of practice.
2. Incorporate this information into training and support strategies based upon patient health status and preference, and best practice standards of care.
3. Educate the patient and family about their illness and its prevention and the maintenance of future health.
4. Assist and support patient in goal-setting, progress reviews, and outcomes of self-management activities.
5. Partner with of all members of the healthcare team, including consultant, to provide patient-centered care.
6. Demonstrate professionalism and adherence to ethical principles.
7. Understand non-clinical roles and boundaries in everyday practice, and know the processes for assuring patient needs are met.
8. Maintain an up-to-date log of all patient contacts, new patient consultation, and health self-care management progress.
Interpersonal and Communication Skills
Goal:
Health coaches must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, families, and professional associates and support positive outcomes for patients.
Objectives:
1. Participants will define the concept of culture, the Appalachian culture, and how cultural filters influence health, self-care management, and beliefs about medical treatment.
2. Participants will explain the impact of health literacy on patient care and outcomes, and give examples of health literacy tools.
3. Participants will demonstrate communication basic skills: listening, asking open ended questions, showing empathy, conflict resolution.
4. Participants will identify the 5 stages of behavior change and the use of Motivational Interviewing to facilitate change.
Reference Sources
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*Patient Navigation and the Healthcare System*Preventive Healthcare 101 *Introduction to the Healthcare System *Chronic Disease Overview. Colorado Patient navigator training. Free eLearning tutorials.
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