Health Coach Competencies Gather essential and accurate information about patients in target population Communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and families Make informed decisions on care management approach to goal setting based on patient information and preferences, communication and partnership with providers, and evaluation of patient clinical data Develop and carry out, and document patient self-management plans Counsel and educate patients and their families Use information technology to support patient care decisions and patient education Perform competently all activities considered essential for the area of practice Provide health care management services aimed at reducing disease complications, preventing health problems or maintaining health Work effectively with all health care professionals, including those from other disciplines, to provide patient-focused care Know how to access resources available within and external to of the medical home Health Coach Overview Goals: Participants will articulate the role of health coaches to the primary care setting and be prepared to apply learned principles to their scope of practice Health coaches are expected to: Provide care management of patients with chronic illness including diabetes, hypertension, hyperlipidemia, asthma, and chronic pain Participate actively in sharing of information and ideas with patients, providers, and other members of the health team Demonstrate knowledge and skills in areas of prevention and chronic disease management and be able to provide this education to patients Perform assessments and identify patient needs on an individual basis Provide ongoing communication to providers and patients regarding patients needs and progress Document all patient care activities and perform data analysis of the population’s progress on a monthly basis Objectives: Participants will demonstrate knowledge of key concepts learned through participant feedback, case examples, and scoring at least 80% on final test Each participant will be able to list the indications for health coaching in the patient centered medical home -110/18/2022 Participants will be able to describe evidence based practices within the primary care setting: Community-Based Medical Home, Patient Centered Care, and Chronic Care Model Participants will know the history and evolution of patient navigation concept, care management, and health coaching and be able to identify similar programs Participants will be familiar with practices and policies specific to the primary care center: Human Resources, HIPAA, Customer Service, Standards of Care, Care Transitions, Insurance Care Management, Risk Management, and Program Outcome and Quality Reports Knowledge of Chronic Conditions Goal: Care Managers must demonstrate competence in the knowledge of chronic conditions, implications to care in the community-based medical home, as well as the application of this knowledge to the identification and self-care management planning of patients with chronic disease Objectives: Participants will describe basic health promotion, prevention, and risk factors for disease a) Nutrition b) Exercise c) Risk factors (genetic, environmental, lifestyle) d) Screening e) Early detection and intervention Participants will demonstrate knowledge of chronic conditions and the application of this knowledge to patient support and planning in the community-based medical home Targeted chronic conditionsf) Diabetes g) Hypertension h) Hyperlipidemia i) Heart Disease j) Asthma k) Pulmonary Disease l) Obesity m) Depression n) Chronic Pain -210/18/2022 Patient Care Management Goals: Health coaches must be able to provide meaningful patient support and education on selfmanagement of chronic disease that is compassionate, culturally appropriate, and effective Skills and interventions will be based upon evidenced-based proven models and best practices for chronic care models in the community medical home Health coaches will demonstrate respect and compassion for others, manage conflict, and behave in a manner consistent with the policies of the health center Health coaches will act in an ethical fashion with sensitivity toward to differences between themselves and their colleagues and patients Objectives: Obtain comprehensive needs and barriers assessment based upon learned models of practice Incorporate this information into training and support strategies based upon patient health status and preference, and best practice standards of care Educate the patient and family about their illness and its prevention and the maintenance of future health Assist and support patient in goal-setting, progress reviews, and outcomes of self-management activities Partner with of all members of the healthcare team, including consultant, to provide patientcentered care Demonstrate professionalism and adherence to ethical principles Understand non-clinical roles and boundaries in everyday practice, and know the processes for assuring patient needs are met Maintain an up-to-date log of all patient contacts, new patient consultation, and health self-care management progress Interpersonal and Communication Skills Goal: Health coaches must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, families, and professional associates and support positive outcomes for patients Objectives: Participants will define the concept of culture, the Appalachian culture, and how cultural filters influence health, self-care management, and beliefs about medical treatment -310/18/2022 Participants will explain the impact of health literacy on patient care and outcomes, and give examples of health literacy tools Participants will demonstrate communication basic skills: listening, asking open ended questions, showing empathy, conflict resolution Participants will identify the stages of behavior change and the use of Motivational Interviewing to facilitate change -410/18/2022 Reference Sources The Human Body, Diabetes, Nutrition, Obesity, and Asthma; Training Modules TTUHSC Computer Modules Texas Tech University Health Sciences Center School of Nursing, Transformacion Para Salud: Patient Navigator Curriculum Redistributed PowerPoint presentations courtesy of New River Health Association, Inc *Patient Navigation and the Healthcare System *Preventive Healthcare 101 *Introduction to the Healthcare System *Chronic Disease Overview Colorado Patient navigator training Free eLearning tutorials www.patientnavigatortraining.org The Harold P Freeman Patient Navigation Institute Http://www.hpfreemanpni.org/the-program Patient Centered Medical Home (Video 4:38 ) http://www.emmisolutions.com/medicalhome/transformed/english.html Current Health Reform and Legislation http://kff.org/health-reform/fact-sheet/summary-of-new-health-reform-law/ http://www.healthit.gov/policy-researchers-implementers/hitech-act-0 http://www.healthit.gov/patients-families/video/health-it-you-giving-you-access-your-medical-records (Video 3:00) Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) http://www.cdc.gov/chronicdisease/index.htm The Shape We’re In: A Charleston Gazette Series Stories and most photos by Kate Long Published in the Charleston Gazette between February 2012 and May 2013 It received the top national public health award of the Association of Health Care Journalists The series was partially funded by a Dennis A Hunt Fund for Health Journalism fellowship, administered by the California Endowment Health Journalism Fellowships at the University of Southern California’s Annenberg School for Communication and Journalism http://theshapewerein.wordpress.com/ West Virginia Burden of Chronic Disease 2008 http://www.cdc.gov/chronicdisease/states/pdf/west_virginia.pdf The Impact of Chronic Disease in West Virginia http://www.wvdhhr.org/bph/oehp/hsc/pubs/chronickidneydisease/ckdfinal.pdf -510/18/2022 NAMI Depression and Chronic Illness Fact Sheet http://www.nami.org/Template.cfm? Section=Depression&Template=/ContentManagement/ContentDisplay.cfm&ContentID=88875 Tobacco, Alcohol, and Drug Abuse Publications http://www.drugabuse.gov/publications/term/47/Health%20and%20Medical%20Professionals State of Tobacco Control 2013 http://www.lung.org/assets/documents/publications/state-of-tobacco-control/state-of-tobaccocontrol-2013.pdf Obesity Statistics 2012 http://www.heart.org/idc/groups/heartpublic/@wcm/@sop/@smd/documents/downloadable/ucm_319588.pdf West Virginia Obesity Profile 2012 http://www.cdc.gov/obesity/stateprograms/fundedstates/pdf/west-virginia-state-profile.pdf Choose MY Plate Resources http://www.choosemyplate.gov/print-materials-ordering.html Physical Activity Guidelines for Americans http://www.health.gov/paguidelines National Heart, Lung, and Blood Institute http://www.nhlbi.nih.gov/ American Heart Association http://www.heart.org/ WVSBIRT Toolkit West Virginia Screening, Brief Intervention, Referral and Treatment, WV Department of Health and Human Resources, Bureau for Behavioral Health and Health Facilities, Division on Alcoholism and Drug Abuse http://www.dhhr.wv.gov/bhhf/resources/Pages/DADA_Resources.aspx Hyperlipidemia 2012 Fact Sheet http://www.hormone.org/sitecore%20modules/web/~/media/Hormone/Files/Questions%20and %20Answers/Heart%20Health/FS_CMD_Hyperlipidemia_EN612.pdf#search=%22hyperlipidemia %22 Heart Disease and Stroke Prevention Fact Sheets http://www.cdc.gov/dhdsp/library/fact_sheets.htm Publications and Resources on Nutrition, Physical Activity, and Weight Control -Weight-control Information Network(WIN) – an information service of NIH- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) -610/18/2022 http://win.niddk.nih.gov/Publications/index.htm The Community Health Worker's Sourcebook: a Training Manual for Preventing Heart Disease and Stroke US Department of Health and Human Resources, Centers for Disease Control and Prevention, Division of Heart Disease and Stroke prevention Available at: http://www.cdc.gov/dhdsp/programs/nhdsp_program/chw_sourcebook/ Health Literacy Universal Precautions Toolkit DeWalt DA, Callahan LF, Hawk VH, Broucksou KA, Hink A, Rudd R, Brach C (Prepared by North Carolina Network Consortium, The Cecil G Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, under Contract No HHSA290200710014.) AHRQ Publication No 10-0046-EF) Rockville, MD Agency for Healthcare Research and Quality April 2010 Available at: http://www.ahrq.gov/professionals/quality-patientsafety/quality-resources/tools/literacy-toolkit/ Partnering in Self-Management Support: A Toolkit for Clinicians Schaefer J, Miller D, Goldstein, M, Simmons L Cambridge, MA: Institute for Healthcare Improvement; 2009 Available at: http://www.ihi.org/knowledge/Pages/Tools/SelfManagementToolkitforClinicians.aspx WV Asthma Fact Sheet 2012 http://www.wvasthma.org/Portals/4/Asthma%20in%20WV%20Fact%20Sheet%20101812%20(2).pdf Chronic Obstructive Pulmonary Disease: An Overview of the problem in West Virginia http://www.wvdhhr.org/bph/hsc/pubs/other/copd_an_overview_in_wv/copd2010.pdf Toolkit: Addressing the Issue of Chronic pain in Older Adults http://www.theacpa.org/uploads/documents/ToolKit_Older%20Adults.pdf The Role of Culture in Health Literacy and Chronic Disease Screening and Management http://anthropology.arizona.edu/sites/anthropology.arizona.edu/files/u3/Shaw%20et %20al_JIMH_new.pdf Food, Culture, and Diabetes in the United States Kulkarni Karmeen D American Diabetes Association doi: 10.2337/diaclin.22.4.190Clinical Diabetes October 2004 vol 22 no 190-192 http://clinical.diabetesjournals.org/content/22/4/190.full Appalachian Culture Module WVU Center for excellence in Disabilities The Allied Health Project: Nutrition and Health Promotion is funded by the U.S Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions Collaborative project of the Center for Excellence in Disabilities, the Division of Occupational Therapy and the Division of Physical Therapy at West Virginia University, Robert C Byrd Health Sciences Center http://www.aucd.org/docs/Appalachian%20Culture%20Module.pdf Doyle D, Stein L Type Diabetes: A Practical Approach NASW workshop H15 May 2013 http://www.naswwv.org/dmgnt_files/H%2015%20Doyle%20Stein%20Diabetes%20Mgmt %20Slides.pdf -710/18/2022 Handouts http://www.naswwv.org/dmgnt_files/H%2015%20Doyle%20Stein%20Diabetes%20Mgmt %20Handout.pdf Online Center for Self-Management Resources Marshall University Center for Rural Health Licensed to offer the Stanford University Chronic Disease Self-Management Programs http://livewell.marshall.edu/SelfManagement/ MI Principles and Approach http://motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20& %20Approach20V4%20012911.pdf www.motivationalinterviewing.org http://motivationalinterview.net/ The Four Agreements Summary http://www.humanpotentialunlimited.com/Summary-content.html Forbes - Self-Promotion Is Not Crucial (Unless You Want To Get Ahead!) http://www.forbes.com/sites/margiewarrell/2013/04/29/self-promotion-is-not-crucial-unless-youwant-to-get-ahead/ -810/18/2022 ... medical home Health coaches will demonstrate respect and compassion for others, manage conflict, and behave in a manner consistent with the policies of the health center Health coaches will act... Current Health Reform and Legislation http://kff.org /health- reform/fact-sheet/summary-of-new -health- reform-law/ http://www.healthit.gov/policy-researchers-implementers/hitech-act-0 http://www.healthit.gov/patients-families/video /health- it-you-giving-you-access-your-medical-records... Disabilities The Allied Health Project: Nutrition and Health Promotion is funded by the U.S Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions