Population Health Overview

Population Health

Expectations of a Health Coach:

The health coach will:

  • Identify all needed preventive health maintenance, immunizations, and chronic disease interventions
  • Work with patients and families on Self-Management Support
  • Coordinate Care across the healthcare system

Self-Management Support:

While the Health Coach will lead Self-Management Support; it takes the team, including you, to make it work. Self-Management Support includes:

  • Setting short and long-term goals for self-management of chronic disease
  • Addressing medication adherence
  • Creating a plan for “Health Behavior Change” to assess and work on your readiness to change and identify and overcome barriers
  • Planning for follow-up visits between regular clinic visits
  • Providing or arranging needed patient education regarding specific or general health care topics
  • Communicating face-to-face in the office setting, by telephone, or by e-mail

Coordination of Care:

Coordinating where, when, and how you receive healthcare services can be complicated. The Health Coach will help navigate your care by:

  • Assisting as liaison with patients and their families to physicians, clinical staff, and other healthcare departments
  • Acting as a liaison with hospitalized patients and the clinic; and following up with patients by phone shortly after hospital discharge
  • Assisting patients in appropriately accessing healthcare services in a timely manner to prevent unnecessary emergency department visits and acute hospital admissions
  • Arranging appropriate transportation for required visits and services
  • Acting as a liaison with specialty clinics, including dentist, podiatrist, ophthalmologist and cardiologist
  • Proactively act as your patient advocate, responding to and working to resolve your concerns and address barriers of care coordination
  • Providing a link to community resources

For a physician referral, call: (641) 648-7035

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