Welcome back to Part 2 of our Coaches Corner interview series, featuring Joan Parker from Cornerstone Family Practice in Guttenberg, Iowa. Part 1, published in the April newsletter, discussed their innovative program to reduce hospital readmissions. Please click here to learn more.
The Clinical Health Coach training is always interested in sharing how coaching models play out within organizations.
Interview: Joan Parker, RN, BSN, Ambulatory Clinic Coordinator, Health Coach
|Amy:||How do patients get referred to the health coaches at Cornerstone Family Practice?|
|Joan:||Health coaching referrals come from four different sources. Inpatient referrals are generated from the hospital-based social worker. The coaches work in collaboration with the social worker and initiate contact with patients while they are in the patient care unit. The second visit is during their post hospital clinic visit which is typically a face-to-face interaction. A second source for coaching referral comes from the physicians. Providers often refer for reasons such as weight loss or chronic condition management, diabetes being common. Candidates are also identified through clinical data, tracking and referring those with high hemoglobin A1Cs (greater than 9) as an example. The coaches reach out to engage these individuals and while some decline health coaching services, others are ready and very willing to participate. Lastly, Cornerstone participates in the Medicaid Health Home program, and receives referrals through the Iowa Medicaid Managed Care Organizations. Colorful brochures have been developed to help market the program and explain the services to patients. The brochures include pictures of the staff, and describe their roles. This has worked well for patients who were at first a bit hesitant.|
|Amy:||What does a health coaching visit look like and how often do the coaches follow-up with patients?|
|Joan:||The goal is to start with at least one face-to-face contact with each and every patient, as it helps to build trust and connection. Thereafter, it is based on the health coach and individual. Not every condition warrants a week-to-week follow up and they look to the individual to help manage that. Most patients let them know if they may need more hand-holding, while others are more independent.|
|Amy:||How to the health coaches stay in communication with each other and the healthcare team?|
|Joan:||Supervisory support is important to encourage weekly (Monday) meetings. The team discusses successes, barriers and they brainstorm ideas around patients that are harder to reach. They talk about who they have touched (or haven’t) and their concerns. A form is used to track these interactions, including the number of patients seen in person, versus telephonically. As a sort of “care process” for the coaches, an action plan is developed for each patient to determine the next step. Each week, these patient encounters are reviewed, creating both support and accountability for the staff. During the week, Joan is always available for additional consultation during the week. Joan’s final comments, “The coaching process is not black and white… it evolves. What works with one patient doesn’t always work for others- even with many of the same conditions.”|