Health Coach

About This Role

This health coach role involves implementing a collaborative process of assessment for the Health Home At-Risk project and Health Home eligibility. The coach will manage population health, coordinate care for patients, provide education and advocacy, and regularly evaluate patients on their caseload. The role reports to the administrative director and collaborates with a licensed Registered Nurse.

Responsibilities

• Use registries to identify patients with newly diagnosed, undiagnosed or poorly controlled chronic conditions and schedule follow-up appointments
• Conduct outreach to patients with overdue screenings or upcoming appointments
• Perform intake and assessment of patients with newly diagnosed or poorly controlled chronic conditions, screen for Health Home eligibility, and check Health Home enrollment
• Screen for behavioral health and substance use problems, including depression (PHQ), alcohol abuse (AUDIT), substance abuse (DAST) and smoking status
• Reinforce education provided by PCP or nurse on management of the chronic disease, provide self-management tools, and review how to use those tools
• Establish goals and create a care plan with the patient
• Lead and participate in Diabetes Prevention and self-management workshops
• Organize and participate in community events and fairs
• Work with patient to mitigate impacts of social factors on health and functional status, e.g. by arranging transportation for patients
• Conduct post-visit review of next steps with patient
• Coordinate care, assist with referral management, and conduct between-visit monitoring and outreach
• Track and follow up on test results to ensure patient and caregiver take appropriate next steps as needed
• Serve as primary care practice's first point of contact during post-discharge care transition from hospital or emergency department
• Work with practice's performance improvement team
• Assist in scheduling huddles and other internal team meetings
• Perform all other duties as requested

Requirements

• High School Diploma or GED required
• MA/LPN/PCT, or other clinical support staff member
• Training or knowledge of vital signs, the use of standardized assessments of basic medical and substance use history and symptoms, and Motivational Interviewing, including goal setting
• Experience with public speaking and interviewing
• Ability to work in surroundings with degree of dust, noise, etc. without undue discomfort
• Ability to hear, talk, walk, stand, bend and stretch
• Ability to read, write and interpret documents
• Ability to sit for long periods of time at desk to perform job functions