Health Coach Program in a Medical Group Improves Self-Care and Decreases Readmissions for High-Risk, Chronically Ill Patients

Problem Addressed

Disease management vendors across the country contract with health plans to offer telephone coaching to patients with a variety of chronic diseases, with the goal of preventing secondary complications of chronic illnesses and, therefore, reducing health care utilization.  While generally considered to be effective, externally run disease management programs exhibit shortcomings that limit their impact on patient health:

• Limited patient uptake: The average enrollment rate for disease management programs that contact  patients on behalf of health plans is only 7-13 percent, meaning that many high-risk patients are not being served.¹ This may be because health plans often use out-of-date claims data to identify eligible individuals. One study found wide variability in health plans’ ability to identify populations eligible for disease management programs due to data quality issues.²
• Limited influence on physicians: A study found little evidence that disease management nurses are able to influence physician decisions through their recommendations about patient care needs.²
• Inability to coordinate services: Disease management nurses employed by vendors typically do not have access to practice electronic health records or scheduling systems, and therefore often cannot make referrals for needed services. 

Description of the Innovative Activity

Nurses trained as health coaches are embedded into physician practices and periodically contact patients to offer personalized information and support regarding the patients' chronic illnesses. Elements of the health coaching program include the following:

• Eligible patients: Individuals targeted for the intervention include patients with chronic diseases, including diabetes, congestive heart failure, hypertension, and coronary artery disease. Each eligible patient is offered a health coach. 
• Patient call lists: A file of patient information drawn from an electronic medical record (EMR) is regularly sent by Dartmouth-Hitchcock to Health Dialog, a disease management company that uses the file to create lists of patients for the health coaches to contact.
• Health coach duties: Each health coach receives a patient list, references the EMR to access additional clinical information on each patient, and then calls each patient. Specific duties include the following:
  
  • Initial introduction: During the initial call to patients, coaches introduce themselves as nurses in the patient’s primary care practice, and explain how the program will work.
  • Ongoing services: Services provided by health coaches are highly dependent upon individual patient circumstances but typically include motivational counseling and education specific to the patient's disease and health status. The health coach decides what services are needed, although the physician may also suggest certain services or conversations. (Because health coaches are located within the practice, they build collaborative relationships with the physicians and nurses.) Specific duties include the following:
    • Providing evidence-based health care information to patients by telephone, during office visits, by distributing educational materials, and in group class settings.
    • Making followup phone calls within 2 days of hospital discharge to ensure that patients understand their medications and that a followup visit with the physician has been scheduled.
    • Offering care coordination when needed (e.g., advocating for visiting nurse services or social services).
    • Accepting calls from patients with questions or concerns; the coach will either provide the information requested or refer the patient to the physician.
    • Making as-needed face-to-face visits. While the majority of patient outreach is by telephone, health coaches may have some face-to-face visits with patients; for example, physicians may ask coaches to meet with patients who are having particular difficulty in complying with their care plan.
• Use of EMR and disease registries: Health coaches have complete access to the EMR system. By accessing the patient’s medical record, the health coach has real-time, in-depth knowledge about the patient’s health status and can tailor the discussion to the patient’s needs. Health coaches also use Dartmouth-Hitchcock’s disease-specific patient registries to help prioritize patient calls and to address particular gaps in care during the patient interaction. In addition, a function in the EMR allows the health coach to notify the primary care physician that a particular diagnostic test is needed, facilitating the scheduling of needed care.

References/Related Articles

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Results

The health coaching program has attracted many more patients than the typical, outsourced disease management program, and has also reduced readmission rates and generated significant overall cost savings. 

• High patient enrollment: Roughly 77 percent of eligible Dartmouth-Hitchcock patients have agreed to participate in the program, much higher than the typical 7-13 percent enrollment rate achieved by Health Dialog-led programs. Approximately 3600 patients have been coached to date.
• Decline in readmission rates: The program prompted a statistically significant decrease in the readmission rate of the targeted patient group; the average readmission rate for patients aged 65 and older dropped from 15.6 to 13.7 percent, a reduction that has been sustained for over a year.
• High quality and lower costs: Dartmouth-Hitchcock met all of the quality measures set forth by the Centers for Medicare and Medicaid Services (CMS) Physician Group Practice (PGP) Demonstration Project and saved CMS $2.7 million. However, this level of savings did not meet the threshold for the clinic to receive a financial award in the first year.  In year 1, Dartmouth-Hitchcock met all of its quality targets except one; year 2 data has yet to be validated by CMS, but Dartmouth-Hitchcock believes that all quality targets were met. (See Context of the Innovation for more information on the PGP Demonstration Project.) 

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

Key steps in the planning and development process include the following:

• Development of initial list of eligible patients: With assistance from the Dartmouth-Hitchcock information technology department, the clinic identified Medicare patients who had one or more of the conditions targeted by the PGP Demonstration Project.
  Identification of those patients at highest risk: Clinic physicians developed an algorithm to determine which patients were at greatest risk for hospitalization or complications. These patients became a priority for the intervention, with lower-risk patients to be enrolled if health coach capacity were available. 
• Development of patient call list: Health Dialog developed patient call lists with basic clinical information that were distributed to the health coaches.
• Development of registries: The Dartmouth-Hitchcock information technology department created disease-specific registries that list patients with each of the target chronic illnesses and identify gaps in care based on evidence-based recommendations. Registries only reflect care provided at Dartmouth-Hitchcock Clinic. 
• Health coach training: Health Dialog provided 2-week training for coaches, who were nurses. Training focused on Health Dialog’s disease management process, up-to-date chronic condition guidelines, assessment of patient readiness for change, proactive problem-solving, and motivational interviewing.

Resources Used and Skills Needed

• Staffing: Dartmouth-Hitchcock employs six health coaches, each of whom has a significant amount of clinical experience. Each coach serves an undetermined number of patients. (Because the frequency of health coach conversations with each patient varies significantly depending upon the needs of individual patients, Dartmouth-Hitchcock cannot estimate the number of patients per coach). The program also required information technology staff to support the development of patient lists and disease registries.
  
• Costs: The costs of the program include the health coach salaries and benefits as health coach services are not funded by health plans. While CMS did not provide money to fund the infrastructure needed to build the program, Dartmouth-Hitchcock may be eligible to receive some gainsharing funds from CMS as a part of the PGP demonstration project; the clinic has an agreement with Health Dialog to share any financial gains awarded. In the first year of the program, Dartmouth-Hitchcock employed six health coaches (5.75 full-time equivalents), who coached 1723 patients at a cost of $381,000.

Funding Sources

Dartmouth-Hitchcock Clinic; Health Dialog

Getting Started with This Innovation

• Ensure that health coaches receive proper training regarding motivational interviewing and assessment of patient readiness for behavior change.
• Employ a dedicated full-time coaching staff. If existing practice nurses are given coaching responsibilities to fold into their regular duties, health coaching will likely receive low priority and may not occur.

Sustaining This Innovation