Population Health-Expanding roles of Health Coaches and Navigators
Volume 5 of 10
The key factor in accomplishing the larger vision of growth, preventative care, a healthy community, and a successful organization is to pull it all together with a dynamic and adaptable Population Health Department. You will find challenges with provider buy-in initially, as mentioned status-quo is not a viable solution. Building the team with coordination from the lead physician, administration, and the Population Health Department is essential to set common goals and strategies that will produce results and naturally achieve measures in the aspect of accountable care and provider payment models driven by value.
The roles of the Health Coach and Navigator, of course, carry several different areas of focus or specialty from one organization to the next. I feel the most successful programs can recognize their current needs, and adapt these roles to engage in meeting their goals. Navigators are a great resource to gather information on care gaps and to identify opportunities for Medicare Annual Wellness Visits, as shared in a previous article (Volume 4). Establishing a process that tracks these opportunities and transparently communicates it to all the providers is invaluable. Doing this will challenge the providers to meet their goals, it also allows visual clarity to discuss barriers and share successes. Care gaps are a large concern for value-based care and preventative health in general. Navigators will be able to run reports in the EHR/disease registry to seek out initiatives for the gaps which include mammograms, colonoscopies, and immunizations that may have been overlooked. Chronic care disease interventions will pay dividends downstream by decreasing readmissions and emergency room visits.
Health Coaches are the vital link between patients and their caregivers. Health coaches have multiple roles of care coordination, self-management support, quality improvement, and they should be staunch patient advocates. You want your Health Coach to work closely with the provider group to develop standard work, closing care gaps that otherwise may be overlooked. Having these standards in place makes it easier for the patient to receive their care in one visit. Health coaches are the frontline of Population Health, and utilizing them to their maximum potential will quickly show a positive return on investment.