About This Role
This health coach role supports a care team by providing safe, therapeutic, and efficient care and services to patients. The role focuses on disease prevention, early screening, testing, and treatment, and helps patients manage their chronic diseases. It involves assisting in patient care and instructing patients and their families as directed by providers.
Responsibilities
- Provide support to patients for clinical outcome management and healthy lifestyle information, including appointment coordination and health system navigation
- Complete and thoroughly document transitions of care calls for moderate risk patients discharged from Hospital/ED
- Arrange follow-up services and identify issues and concerns to appropriate staff as needed
- Communicate and share information with providers and care team members on issues and concerns such as transition of care between hospital, skilled nursing facility, rehab, and home care
- Support the care team by functioning as a health coach for disease prevention, early screening and testing, and treatment, and for helping patients manage chronic diseases
- Generate/review payer lists of patients to proactively manage patients and families with service needs for prevention or chronic conditions
- Provide direct care management interventions for patient populations where WellSpan is at financial risk by completing the Shared Care Plan
- Assist patients with goal setting, creating action plans to manage their health, addressing barriers to patient adherence to treatment plans, and assisting with referrals utilizing wellness and self-management programs
- Assist patients with instruction and health literacy through teach-back of any new medications, instructions, and referrals
- Monitor outcomes while following up on interventions identified in the care plan within scope of practice
- Provide health care information materials and review with patient and/or family members as directed by providers
- Maintain the patient
