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At Asian Health Services, a multi-site organization in Oakland, CA, that serves Asian-American and Asian immigrant patients, each provider is paired with a health coach. This team approach ensures that each patient gets the care they need, understands their care management, and is actively engaged in their health care.
Health coaches are medical assistants who have received additional training in motivational interviewing (such as the “ask-tell-ask” technique), pre-visit planning, chronic illness monitoring, and electronic health record (EHR) management. Training is ongoing, and members of the multi-disciplinary team in each clinic lead the educational sessions.
The day before a patient's visit, health coaches review notes from the previous visit and prepare charts, determining if a patient received care elsewhere or if new lab results are available since their last visit. On the day of the visit, health coaches attend a pre-clinic huddle with the patient's provider. During the visit, the coach measures the patient's blood pressure, reconciles the patient's current medication regimen, and works with the patient and provider to set the visit agenda and action plan. After the provider leaves the exam room, the coach stays with the patient to discuss what happened during the provider visit and assess if the patient understood the provider's recommendations.
After a successful pilot program, the organization chose to expand its health coach program. In this high-needs population—approximately 60 percent of the patients are on Medicaid, and many of the remaining patients are uninsured or underinsured—the organization estimated many of its patients would particularly benefit from health coaching. Using plan-do-study-act cycles to refine and perfect the health coaching process, Asian Health Services successfully expanded its health coaching program from its initial pilot. The organization credits its success to the plan-do-study-act cycles and the leadership support and program champion which were vital to the success of the pilot.
The coaching program is now active in all clinic locations. The organization continues to evolve and evaluate the program, such as by collecting outcomes data to assess the impact of motivational interviewing or by reviewing cycle times. Further plans are in development, including expanding the health coaching program to include licensed vocational nurses that will target patients with diabetes.
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