Health Coaching Center of Excellence

Transcription

1 Health Coaching Center of Excellence

2 Why Health Coaching? While physicians diagnose and treat illness, they don t always have the time to teach their patients to take proactive steps with nutrition, lifestyle and stress reduction. Health Coaches assist in connecting the dots by helping to empower chronic members to self-manage their conditions, at-risk members to refrain from attaining a lifelong condition and most importantly low-risk members to stay healthy; ultimately, enabling organizations to potentially reduce and avoid costs and improve productivity. Cerner Health Coaching is designed to: Position organizations to deliver a unique benefit offering Promote better health through meaningful interactions Create an opportunity to avoid costs through lowered health risks and improved outcomes A team approach Relevant and personalized coaching In addition to evaluating data from claims, we aggregate personal health assessment results, baseline clinical data, and health beliefs data to get a more complete picture of an individual. Our Health Coaches use this data to tailor their interactions and program components for a more personal engagement. Connectedness to primary care Coaches and primary care physicians (PCPs) work together to provide a comprehensive plan for health. The Health Coach helps execute this plan via personalized wellness actions that are driven by the member. Results-driven design We ve designed every aspect of our program with results in mind. We take into consideration: Participation Member experience Clinical risks Financial return-on-investment (based on claims availability) Family Cerner Health Coaches: Promoting a continuity of care plan Health Navigator Health Coach Health is complicated. Cerner Health Coaches help guide individuals to better health by introducing and leveraging each individual s influential health resources whether that be a relationship or available technology. Dietitian Primary Care Physician Primary Care Physician: Establishes a care plan with specific goals related to each member s health Health Navigator: Serves as a liaison between the member and their health team Devices Dietitian/Exercise Specialist: Advises on specific topics related to a member s condition(s) Devices: Provides transparency to a member s progress Family: Acts as member s at-home support system 1

3 Know your population stratification Approach to stratification Each member will fall into at least one of the 11 condition categories. These categories represent the biggest health cost avoidance opportunities. 1 Our overall goal is to keep the healthy stabilized and move those facing challenges into a lower risk category. The population is stratified by data from the following sources: Personal Health Assessment Labs & biometrics Secondary review of claims data (including ICD-9 diagnosis codes) 2 Physician referrals Condition Categories 1. Heart disease 2. Depression, anxiety 3. Asthma 4. Hypertension 5. Diabetes 6. Hyperlipidemia 7. Back and neck pain 8. Obesity 9. Pregnant 10. Healthy but unfit 11. Healthy and fit 1 Based on data from the Agency for HealthCare Research and Quality (AHRQ) Accessible, secure communication Health Coaches can interact with members at home, work or on-the-go via web, tablet, mobile app or face-to-face. Cerner s Health Coaches are certified through evidenced-based health coaching programs. 2

4 Know your population even better Stratification within a condition Once the population is stratified across the 11 condition categories, an additional level of stratification within each condition category specifies low, moderate or high-risk. Depending on a member s risk level, a wellness action plan with program content approved by our medical director will be triggered. An example Note: Some members may fall under multiple conditions. Diabetes example: Easily understand that 17.8% of the population is at-risk for diabetes with 53 low-risk, 72 moderaterisk and 53 high-risk members. Coaching Center for Excellence 3

5 Engage and manage your population on a personal level Personalized action plan Wellness action plans vary by risk level (low, moderate, high). Each member s plan is personalized based on motivations, lifestyle, readiness-to-change, goals and barriers. When our coaches meets with an individual, they help: 1. Establish a wellness action plan and SMART Goals (Specific, Measurable, Attainable, Realistic and Time bound) 2. Identify barriers, motivations and readiness-to-change 3. Encourage continued healthy behavior 4. Recommend condition-specific diet and exercise 5. Review progress and re-assess goals 6. Refer to established client and community resources (EAP, nutrition options, exercise opportunities, local runs/ walks, etc.) An all-encompassing health team Cerner helps every individual create a dedicated health team consisting of a PCP, Health Coach and dietitian and/or exercise specialist, regardless of risk level. Individuals are matched to a PCP based on preferences and health status, if desired. Together the team works to achieve interventions and clinical outcomes outlined by the PCP. Low risk: MAINTAIN Moderate risk: PREVENT High risk: CONTROL Physician (PCP) Confirm maintaining healthy state Set care plan Diagnose, write script (if necessary) and set care plan Health Coach Encourage to continue healthy behavior Diabetes example: Assess current exercise, stress, diet and tobacco use; build knowledge base; and create self-awareness and confidence Wellness action plan: Log exercise, food and weight Confirm compliance, establish action plan and follow-up to review progress, and reassess action plan goals Diabetes example (in addition to low risk): Review PCP care plan and increase skill development Wellness action plan: Promote ADA diet and medication compliance, log BP and consult with an exercise specialist Confirm compliance, establish action plan and follow-up to review progress, and reassess action plan goals Diabetes example (in addition to moderate risk): Teach behavior modification techniques to prevent remission, highlight the health risks of diabetes, confirm PCP appointment Wellness action plan: Log glucose, consult with a registered dietitian, demonstrate knowledge of diet and promote medication compliance Dietitian and Exercise Specialist Educate Educate and set condition-specific diet and exercise regime Educate and set conditionspecific diet and exercise regime Health Coaching Tools and Resources Logs and Trackers Monitoring Tools Health Challenges Educational Resources Food log Water log Fruit/veggie tracker Exercise log Steps log Glucose monitoring Blood pressure monitoring Weight monitoring Device integration Nutrition Challenge Weight-Loss Challenge Steps Challenge Minutes of Activity Challenge Ask a Dietitian Ask a Fitness Specialist HealthWise Knowledge Database Workshops *All tools and resources are available on the Cerner Wellness Portal 4

6 An example: interactive coaching tools LiveWell with Diabetes Condition Live Coaching follow-up Dear Ellie, Thank you for participating in the LiveWell Wellness program. Through the wellness program you have been identified as a candidate for diabetes management. To opt-in to the program, please click the button below to get started. Get Started Your Health Coach Dear Ellie, Based on our conversation, our SMART goal and plan of action is as follows: Specific, Measurable, Achievable, Realistic, Timely SMART Goal: To lose 5 lbs. in 4 weeks Action Plan: Daily food log and 30 minutes of moderate exercise Motivations: High school reunion Barriers: Prioritizing to make time for myself Live well, Your Health Coach 1. Coach invites member to participate in program 2. Coach meets with member and establishes tailored wellness and action plan 3. Coach advises based on member-logged weight and nutrition 4. Coach reviews progress and assigns conditionrelated workshop Interaction example: Coach sees healthy drop in weight and reviews with member what positive shifts in behavior they have made and encourages progress. Coaching Center for Excellence 5

7 Engagement Timeline Setting up a plan for success An engagement timeline is proposed below assuming the contract is signed 60 days prior to program launch. To oversee the coaching programs, each Cerner coaching client will be assigned a lead coach. The lead coach will work to integrate coaching into a client s larger health strategy by gaining knowledge of all existing health resources (EAP, weight-loss programs, etc.) and recommending to eligible members. An example Pre-program preparations Lead coach meets with client to discuss integration of existing health tools and resources Stratify population via claims data, Personal Health Assessments, labs & biometrics and physician referrals Invite eligible members to participate via health coaches sending out invitations Month 1 Program Launch Launch program: health coaches will begin coaching visits Month 2 12 Continued engagement Promote ongoing engagement: number of coaching visits will be based on risk-level Post program analysis Survey participating members used to identify improved qualities in health and life Analyze program impact by looking at engagement, clinical and financial outcomes Cerner Corporation, 2800 Rockcreek Parkway, Kansas City, MO 64117, USA Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information belonging to Cerner Corporation and/or its affiliates which may not be reproduced or transmitted in any form or by any means without the express written consent of Cerner. All Cerner trademarks and logos are owned by Cerner, Corp. All other brand or product names are trademarks or registered marks of their respective owners _v2 6

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