docIntegrating Diabetes Health Coaches Onto the Clinic Teams
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Integrating Diabetes Health Coaches Onto the Clinic Teams
Integrating Diabetes Health Coaches Onto the Clinic Teams STEPHEN FLYNN, MD, MSPH LCDR GWENIVERE ROSE, MS, RD CHINLE SERVICE UNIT NAVAJO AREA IHS Chinle Service Unit Canyon de Chelly, Chinle, AZ Chinle Comprehensive Healthcare Facility Pinon Health Center Tsaile Health Center Chinle Service Unit Chinle Service Unit is a federally run Indian Health Service site with 60 bed hospital and 3 ambulatory health care centers Population: Almost 37,000 Native Americans in 17 chapters (communities) in the central part of the Navajo Nation 180,000 outpatient visits annually Medical Home Model: Primary care based Chinle has embraced the Medical Home model, including team care 4 adult primary care clinical teams (2 IM, 2 FP) Teams initially consisted of physicians, nurse practitioners, health techs, MSAs, and nurses No separate Diabetes clinic CSU Diabetes Team Diabetes Team at CSU Gwenivere Rose, Director of Community Nutrition and Diabetes Services Miranda Descheenie, Diabetes Coordinator Krista Haven, Diabetes Improvement Nurse Stephen Flynn, Diabetes Clinical consultant Health coaches: Duane Begay, Farrah Begay, Shanna Descheenie, Ivan Salabye, Candace Tallis, Denee Yazzie Ed Wagner, Informatics Tech CSU Diabetes Program before Health Coaches In 2011, CSU had 2 diabetes educators Co-located in the clinic area Seeing patients at that time by same day referral from providers Visits were usually after the provider visit More traditional 45 minute patient education visit CSU Diabetes Program before Health Coaches # Visits with diabetes educators were less than desired A major impediment with same day appointments was lack of time by the patients Patients often waited to get roomed to see the provider and also had to wait several hours to get medications in the pharmacy Patients usually declined to see the diabetes educator at the end of the provider visit, because this would add 30-60 minutes more IPC: Improving Utilization of Diabetes Educators First Test of Change DE called patients the day ahead of provider appt to remind about visit and to ask to meet with patient after provider visit RESULTS: did not increase patient contacts significantly IPC: Improving Utilization of Diabetes Educators Second test of change Diabetes educator would see patients with the provider during a usual visit The schedule was previewed by the educator and physician and certain high risk diabetic patients were identified in advance for the educator to see IPC: Improving Utilization of Diabetes Educators The diabetes educator would come into the room with the physician and be introduced as part of the clinic team After the physician finished and left the exam room, the educator would stay to answer questions, provide information and self management support IPC: Improving Utilization of Diabetes Educators These educational interactions were focused and brief, lasting < 10-15 minutes If patient needed more time, the diabetes educator could take the patient back to the education office Of paramount importance was the fact that the diabetes educator would not interrupt the work flow in the clinic IPC: Improving Utilization of Diabetes Educators Results of Second test of change: This process met with great acceptance from the provider, the patients and the diabetes educator Patients were much more likely to visit with the educator then and at future visits Spreading the Success About the time that the second test of change was completed, CSU was in the process of hiring 4 additional health coaches under the Healthy Heart Initiative Under this grant program, the health coaches work with enrolled diabetic patients in a monthly coaching model, using diabetes education and self-management support strategies Based on previous success, we decided to integrate these new health coaches onto the clinic teams Current Use of Diabetes Coaches in the Medical Home INTEGRATED TEAM CARE Diabetes Health Coaches: Primary Roles Provide diabetes education Support patients in having the confidence to manage their health through SMS skills such as goal-setting, action-planning, and problem-solving Provide Care Coordination , Feedback and Follow-up. Who are these Coaches ? Essentially selected for ability and potential and trained on the job with a designed curriculum Preferred: Communication skills Patient teaching experience Knowledge of disease processes Self management support knowledge and skills High school graduate No specific prior certification required Training Diabetic Health Coaches Ongoing education of coaches including workshops, online modules and weekly classes coordinated by Diabetes Improvement Nurse Coaches are trained in Navajo Wellness Model, SelfManagement Support, and Diabetes Competencies. Curriculum based on “Honoring of Gift of Heart Health”, “Balancing Your Life and Diabetes” and “Native Lifestyle Balance” Integrated Health Coach Model of Care Diabetes coaches are assigned to work with specific primary care teams, but do cross-cover Usually 2-3 coaches at every clinic session Diabetes coaches preview the daily clinic schedule to identify higher risk diabetic patients, such as newly diagnosed or poorly controlled diabetics Integrated Health Coach Model of Care Diabetes coaches meet with providers at the beginning of each session to review which patients to see Diabetes health coaches will then see the patient in the exam room, either before, during, and/or after the visit with the primary care provider Treatment plans are reviewed with the providers and patients Integrated Health Coach Model of Care Diabetes coaches can do brief focused SMS teaching in the exam room (Eg, glucometer training, reviewing meds, problem solving, teach back and action planning) If the patient needs more extensive time, the diabetes coach can take to a separate office area (eg, insulin starts) Results of the Integrated Model Health coaches now well accepted and in demand by providers High satisfaction scores from patients and staff Marked increase in pt encounters with diabetes coaches Provided additional services for patients besides diabetes education and self-management support Results of the Integrated Model What else did Health coaches do? Were asked for advice on management by providers and staff Identified and reported unusual management regimens Provided continuity of care Served as liaison between patient and provider Performed follow up phone calls and served as a point of contact Called to remind patients of upcoming appt Provided trouble shooting for issues like glucometers Created digital stories with their patients Attended health fairs Made some home visits Remaining Questions How do we really measure the success of the Health Coach model in the clinic? Patient experience? Patient clinical outcomes? Staff satisfaction? Early results are promising, but more data needed. This summer will mark the end of the first full year of implementation Thank You Questions?
