Coaching Outcomes to Address Changes in Health for Underserved Asians with Co-morbidities

Asian Health Services (AHS) focuses on providing health care to low-income, uninsured, and underinsured patients of the Asian and Pacific Islander community across Alameda County, CA.  It was founded in 1974, and today offers services in 11 Asian languages to close to 24,000 patients annually, 70 percent of whom earn an income at or below 100 percent of the Federal Poverty Level. 

AHS has developed a team-based health coaching model to assist its predominately Asian patients with diabetes and the comorbidity of hypertension through integration of behavioral health care.  Given the distinct cultural and linguistic challenges, and limited knowledge of the healthcare system, comprehensive care and medication treatment plans are complex and require close monitoring.  In this presentation AHS will explain how their program addresses these issues, specifically for treating and controlling diabetes.

In AHS’ program all patients are screened for behavioral health issues, which are tracked through electronic health records and flagged if counseling is needed.  Results are shared with primary care physicians and coordinated team care meetings (a clinician and two health coaches), all of who help to co-manage each patient’s individual treatment plan and lifestyle activities.  The program’s focus lowers high rates of hypertension among patients with diabetes through understanding cultural norms and offering specialized services to help patients make adjustments – counseling, medication management, cooking and education classes. Over time clinical impact was seen through the increase in the proportion of individuals with HbA1C levels less than or equal to 9 (under control).