Health coach

Innovations

Primary Care–Based, Multidisciplinary Teams Provide Care Management Services to Complex Patients, Enhancing Patient Engagement and Reducing Hospitalizations 06/27/16

The San Francisco Health Network embeds multidisciplinary teams within primary care practices to provide “wraparound” services to medically and psychosocially complex patients. Made up of nurses,...

Community-Based Health Coaches and Care Coordinators Reduce Readmissions Using Information Technology To Identify and Support At-Risk Medicare Patients After Discharge 03/23/14

Supported by mobile technology, trained health coaches at Elder Services of Merrimack Valley (an Area Agency on Aging in Northeastern Massachusetts) visit recently discharged Medicare patients in...

Community Health Workers Embedded in Inpatient and Outpatient Clinical Teams Enhance Access to Primary Care and Improve Health Outcomes for Low-Income Patients 03/13/14

The University of Pennsylvania Health System embeds community health workers into its clinical teams at hospitals and medical offices. Following the Individualized Management for Patient-Centered...

State Medicaid Program Pays Additional Capitated Fee to Integrated Primary Care and Mental Health Homes, Leading to Better Outcomes and Lower Costs 03/01/14

The Missouri Medicaid Health Home program provides a per-member–per-month payment to medical homes, including primary care clinics and mental health centers, that adopt an integrated staffing...

Community Health Workers Offer Culturally Tailored Interactive Workshops and Counseling to Filipino Americans, Leading to Improvements in Medication Adherence and Cardiovascular Risk Factors 02/28/14

Based on a community assessment and input from groups serving the Filipino American community, the Center for the Study of Asian American Health at New York University School of Medicine and the...

QualityTools

Safety Net Medical Home Initiative: Resources and Tools 06/16/14

This library of publicly available resources and tools can help safety net providers understand and implement the patient-centered medical home (PCMH) model of care. Users can navigate these free resources by type or topic or by the registry of...

Transitioning Newborns From NICU to Home: A Resource Toolkit 01/24/14

This toolkit for hospitals provides information and resources to improve safety when newborns transition home from the neonatal intensive care unit (NICU). Through a Health Coach Program, the toolkit offers coaches, parents, and families...

Care Transitions Program Toolkit 11/29/07

Through this 4-week program, patients with complex care needs receive specific tools, are supported by a “transition coach,” and learn self-management skills to ensure their needs are met during the transition from hospital to home.

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