A Health Coach disease management model: Evaluating the impact on treatment compliance in community-based settings

Health disparities can inhibit quality healthcare for Medicaid populations. An effective disease management (DM) program that intends to elevate health literacy and establish effective self-management among the disadvantaged must first address barriers to care. RN Health Coaches (HCs) are able to identify the root of healthcare access issues, including transportation, education level, preferred communication approach, language, and even religion. After removing access barriers, HCs are able to provide disease specific education and utilize self-management goals to motivate behavior change. Chronically ill adults (those with diabetes, CAD, COPD, asthma, hyperlipidemia, hypertension, GERD, etc) were enrolled in a community-based program trial. DM interventions were tailored to the population after access barriers were addressed. Additional epidemiological data, such as acuity level and concomitant disease profiles, allowed HCs to further prioritize interventions. Health Coaches provided disease-specific education during self-management sessions and systematic follow-ups, both by telephone and face to face. HCs performed resource location (e.g. community assistance), coordinated testing referrals, appointment reminders, and provided transportation assistance. Coordinated plans of care were created by engaging providers using online health records and case conferences. Self-management goals were linked to education plans according to health status, health literacy level, and determined successive steps to behavior modification. Health status was determined at baseline and quarterly thereafter based on compliance percentage of over 30 established national guidelines such as yearly influenza vaccines, statin therapies for CAD, and an ARB/ACE I medication for CHF. The health status of HC populations in four locations was compared for 12 months. Study results show an immediate (within six months) and sustained increase in treatment compliance across the majority of surveyed chronic disease metrics. Many increases exceeded goals, indicating the efficacy of a complex care coordination/DM approach. Diabetic participants decreased average HbA1C level by 4.3% and increased HbA1C semiannual testing by over 45%. Compliance for ARB/ACE I therapy in CHF participants increased 27.9% on average; statin therapies in CAD increased almost ten percent, and chronically ill participants obtaining a yearly influenza vaccine increased 30% overall. Complex care coordination that includes not only disease-specific education but also reduced barriers to care and progressive self-management goals displayed notable results. When such an approach was taken, Medicaid participants' chronic illness indicators improved. The ability of HCs to leverage better access, goals, and education in a complex population with a focus on the individual is evident in these dramatic improvements in health status.