By 2030, an estimated 170 million Americans will have at least one chronic condition, a big jump from today’s estimation of 133 million or almost half the population. Primary care physicians are at the forefront of providing the care these patients need, but some gaps need to be filled like the crucial time in-between office visits.
To ensure continuity of care, Medicare launched the Chronic Care Management (CCM) program to help physicians ensure chronic care patients are assisted and closely monitored in every step of their care journey. For CCM to work, it requires the active participation of the patients, particularly in complying with the care instructions. To keep patients participating and engaged, health coaching has proven to be an important element of CCM to aid patients in complying with their care plans and reaching their health goals.
What is health coaching?
Health coaching provides patients with the knowledge, tools, and skills to manage their illnesses. Health coaches are usually nurses or specially trained medical assistants. Under CCM, they call the patients once a month in-between office visits to discuss their condition, coordination of specialty visits, teach them how to self-manage, and overcome difficulties they encounter. There are instances wherein not only the patients get educated, but also their caregivers and their families.
The role of health coaches in chronic care management
The goal is to encourage patients to abide by all the care instructions and adhere to the medication plan. The health coaches provide the information about the patient to the physician, but more importantly, they are key in making patients engaged and more responsible for their health. It is similar to an old adage of teaching people, or in this case, patients “how to fish” after the physician has provided the “fish” to start them off on staying healthy. For elderly sick patients over 65 years old, health coaches are central to the care coordination among different providers for they are instrumental in improving patient adherence, patient experience, and finally, patient health outcomes.
Health coaching provides the patients
Health coaching provides the patients with the following benefits:
- Acquire illness-specific skills and self-management support that promote the adoption of healthy behaviors and lifestyle changes
- Access important information about their disease, which includes getting the right answers to their queries about their conditions, medications, and other treatments
- Assist in navigating the healthcare system, including locating and participating in other medical services and tapping additional resources
- Receive emotional support, which has been a valuable service for patients to manage the emotional impact of their chronic condition
How health coaching helps CCM?
1. Promotes adherence
Chronic diseases last for at least a year and could negatively affect a patient’s quality of life. These conditions include arthritis, diabetes, heart disease, hypertension, and high cholesterol. Unfortunately, a good percentage of patients suffering from chronic diseases are unable to manage their condition with medication non-adherence as the primary reason.
Health coaching can provide the right push to promote adherence and compliance to care plans by chiefly educating patients. If patients can have access to the right information and support they need to abide by their care plans, then this could alter their behavior with regard to their care. With higher adherence comes prevention of an escalation, ER visit, or a costly hospitalization. This is why CCM is the solution adopted by practices to resolve the challenge of having non-face-to-face care coordination by using a comprehensive care plan that covers all facets of care like the physical, functional, behavioral, social, and financial goals.
2. Overcomes barriers
CCM continues the care because if chronic conditions are left unchecked, they can lead to failed treatments, serious complications, additional illnesses, and even death. Some chronic conditions can be managed with the right medications, but others require some radical changes to lifestyle and diet. Even with the best treatment plan, patients may not be able to comply because of forgetfulness, side effects, or other personal concerns. This is why health coaching is crucial in managing chronic diseases to assist patients to overcome their care challenges.
In addition, there are patients with multiple chronic conditions that may prove to be challenging for a primary care physician practice to manage on their own. Employing the help of health coaches has proven to be effective. Though health coaching itself is not new, its emergence as a valuable service for medical practices has been valuable in the steady adoption of CCM. Evidence supports that health coaching in CCM results in better health outcomes, economics, and provider experience. Providers find patients who are CCM-enrolled and health-coached to be less demanding, thereby facilitating a productive office visit as compared to treating usual-care patients.
3. Provides Revenue
Medicare reimburses CCM services that include a minimum of 20 minutes of non-face-to-face service to every patient every month with the general supervision of a physician. The valuable contribution of health coaches is not only to educate and engage patients but consequently to provide practices a billable service.
Health coaching helps CCM provide the high touch points needed in-between office visits. They equip patients with the skills to self-manage, bridge communications gaps between the physician and the patients, and aid patients in maximizing the services offered by the healthcare system. Health coaches serve as the point of contact in coordinating care programs like CCM.
Health coaching under a service that works
Health coaching improves CCM because it promotes an active partnership between the care team and the patients rather than patients just merely passive recipients of care. CCM as a service works because it improves patient engagement and satisfaction resulting in better health outcomes as patients become more responsible and invested in their health.
Ascent Care Partners (ACP) provides turnkey CCM solutions with highly trained health or “care coaches” serving as an extension of a practice’s clinical team. We utilize a unique patient engagement methodology where we make sure to assign the same care coach to the same patient to foster trust and build meaningful relationships with them. This approach enables our care coaches to pick up even the subtlest changes to a patient’s behavior that could indicate a minor problem and prevent it from becoming a big one. We help primary care physician practices grow clinically and financially.
