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Inspire health. Serve with compassion. Be the difference.
Job Summary
The health coach works collaboratively with a multi-disciplinary team of health care providers to manage targeted patient populations to achieve efficient and effective care delivery through disease management. The health coach will work with patients who have chronic conditions or at risk for a chronic condition in-person, by telephone or via electronic means to educate, counsel and coordinate care across the health care continuum. The health coach will guide and facilitate action oriented goals to improve clinical outcomes, empower patient using evidence-based guidelines, reduce gaps in recommended evidence-based care and reduce frequent hospital admissions and re-admissions. If operating in the PASO capacity, team member will utilize both the Spanish and English languages, work collaboratively with PASOs, AccessHealth and a multi-disciplinary team of health care providers to manage Hispanic patients identified with chronic conditions or at risk for chronic conditions to achieve efficient and effective care delivery through disease management.- To promote consistency in long-term management approaches and optimize treatment for\u00A0patients with targeted conditions.
- To achieve optimal levels of wellness in the targeted patient populations through:
- Participation in the development of a plan of care that improves the patient\u2019s basic understanding of his/her disease process under the supervision of a Care Manager and in conjunction with patient/family, physicians and other health care team members.
- Increasing provider awareness and participation with recommended treatment\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0 modalities.
- Monitoring patient\u2019s condition and addresses lifestyle issues
- Participating in the transition of patients from disease management to care\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0 management\u00A0when specific patient indicators exceed the established threshold.
- Attainment of increased compliance with treatment regimen
- Uses knowledge of health system and community resources to facilitate achievement goals
- Provides health education, identifies barriers to attainment of self- management goals and\u00A0develops strategies to overcome.
- Reduces emergency room utilization and frequency of inpatient admissions.
- Reduces and delays late stage disease manifestations.\u00A0\u00A0 35%
Interdisciplinary Practice \u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0
- Conducts outreach calls to disease management patients to document non-clinical and clinical data for patient assessment, provides health education, engages member in\u00A0appropriate self-care\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0 techniques, shared decision-making and knowledgeable use of medications.
- Participates in the development and execution of the plan of care and disease specific\u00A0interventions.
- Works in collaboration with health system staff, care management and partners as necessary to\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0 provide continuity of care, as necessary.
- Facilitates referrals to other disciplines and community based programs as appropriate to improve\u00A0\u00A0\u00A0\u00A0 patient outcomes.\u00A0\u00A0 35%
Evidence Based Care\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0
- Utilizes and incorporates knowledge of efficiency and effectiveness indicators (PHQ-9 and Patient\u00A0\u00A0\u00A0\u00A0 Activation Measure) when creating plan of care.
- Increases knowledge of best practices, self-management, and standards of care into practice.\u00A0\u00A0 20%
Measurements and Reporting\u00A0\u00A0\u00A0
\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0 * \u00A0Documents in the medical record and other established platforms, accurately reflecting collaborative care\u00A0\u00A0\u00A0\u00A0\u00A0
\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0 planning, intervention and evaluation against defined targets and goals.\u00A0\u00A0 10%
Bachelor's Degree - Health, Wellness or Public Health
1 year - Health Education or Coaching
Knowledge of specific disease states such as diabetes, hypertension, hyperlipidemia, congestive heart failure, chronic obstructive pulmonary disease, asthma, depression and\u00A0tobacco use\u00A0- Required
Experience using motivational interviewing - Preferred
Ability to interpret lab data and biometric results - Preferred
Knowledge of Behavior Change Theory - Preferred
Work Shift
Day (United States of America)Location
RichlandFacility
7002 Value-Based Care and Network ServicesDepartment
70028455 Care TransformationShare your talent with us! Our vision is simple: to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.
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Job Summary
The health coach works collaboratively with a multi-disciplinary team of health care providers to manage targeted patient populations to achieve efficient and effective care delivery through disease management. The health coach will work with patients who have chronic conditions or at risk for a chronic condition in-person, by telephone or via electronic means to educate, counsel and coordinate care across the health care continuum. The health coach will guide and facilitate action oriented goals to improve clinical outcomes, empower patient using evidence-based guidelines, reduce gaps in recommended evidence-based care and reduce frequent hospital admissions and re-admissions. If operating in the PASO capacity, team member will utilize both the Spanish and English languages, work collaboratively with PASOs, AccessHealth and a multi-disciplinary team of health care providers to manage Hispanic patients identified with chronic conditions or at risk for chronic conditions to achieve efficient and effective care delivery through disease management.- To promote consistency in long-term management approaches and optimize treatment for\u00A0patients with targeted conditions.
- To achieve optimal levels of wellness in the targeted patient populations through:
- Participation in the development of a plan of care that improves the patient\u2019s basic understanding of his/her disease process under the supervision of a Care Manager and in conjunction with patient/family, physicians and other health care team members.
- Increasing provider awareness and participation with recommended treatment\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0 modalities.
- Monitoring patient\u2019s condition and addresses lifestyle issues
- Participating in the transition of patients from disease management to care\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0 management\u00A0when specific patient indicators exceed the established threshold.
- Attainment of increased compliance with treatment regimen
- Uses knowledge of health system and community resources to facilitate achievement goals
- Provides health education, identifies barriers to attainment of self- management goals and\u00A0develops strategies to overcome.
- Reduces emergency room utilization and frequency of inpatient admissions.
- Reduces and delays late stage disease manifestations.\u00A0\u00A0 35%
Interdisciplinary Practice \u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0
- Conducts outreach calls to disease management patients to document non-clinical and clinical data for patient assessment, provides health education, engages member in\u00A0appropriate self-care\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0 techniques, shared decision-making and knowledgeable use of medications.
- Participates in the development and execution of the plan of care and disease specific\u00A0interventions.
- Works in collaboration with health system staff, care management and partners as necessary to\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0 provide continuity of care, as necessary.
- Facilitates referrals to other disciplines and community based programs as appropriate to improve\u00A0\u00A0\u00A0\u00A0 patient outcomes.\u00A0\u00A0 35%
Evidence Based Care\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0
- Utilizes and incorporates knowledge of efficiency and effectiveness indicators (PHQ-9 and Patient\u00A0\u00A0\u00A0\u00A0 Activation Measure) when creating plan of care.
- Increases knowledge of best practices, self-management, and standards of care into practice.\u00A0\u00A0 20%
Measurements and Reporting\u00A0\u00A0\u00A0
\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0 * \u00A0Documents in the medical record and other established platforms, accurately reflecting collaborative care\u00A0\u00A0\u00A0\u00A0\u00A0
\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0\u00A0 planning, intervention and evaluation against defined targets and goals.\u00A0\u00A0 10%
Bachelor's Degree - Health, Wellness or Public Health
1 year - Health Education or Coaching
Knowledge of specific disease states such as diabetes, hypertension, hyperlipidemia, congestive heart failure, chronic obstructive pulmonary disease, asthma, depression and\u00A0tobacco use\u00A0- Required
Experience using motivational interviewing - Preferred
Ability to interpret lab data and biometric results - Preferred
Knowledge of Behavior Change Theory - Preferred
Work Shift
Day (United States of America)Location
RichlandFacility
7002 Value-Based Care and Network ServicesDepartment
70028455 Care TransformationShare your talent with us! Our vision is simple: to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.