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The one-year pilot partnership between Mount Sinai St. Luke’s and [easyazon_link identifier=”1284069419″ locale=”US” tag=”harlemworld-20″]City Health Works[/easyazon_link] began in July, and is in the early stages of identifying patients eligible for health coaching to drive better care management.
Individualized health coaches will help patients understand their disease, symptoms, and self-management needs. Health coaches will be charged with helping to empower patients to play a greater role in their chronic care management, including understanding and adhering to medications, acknowledging the importance of a healthy diet, and recognizing the importance of regular wellness and follow-up visits.
City Health Works health coaches have been trained by nurse specialists from Mount Sinai St. Luke’s Heart Failure Team and have been integrated into patient communities. In doing so, City Health Works hopes to reach patients during the critical moments in between office and hospital visits.
Both organizations hope the program will ultimately reduce hospital and emergency department admission rates, a key goal for the New York State Delivery System Reform Incentive Payment Program (DSRIP).
The program has already seen success from embedding health coaches within the community, according to City Health Works Director of Health Coaching and Clinical Partnerships Jamillah Hoy-Rosas.
“Our health coaches, hired from the neighborhoods we serve, pride themselves on developing quality, trusting relationships with patients and helping them achieve the best outcomes,” Hoy-Rosas said in a statement. “We are thrilled to partner with Mount Sinai and the [easyazon_link identifier=”1405167505″ locale=”US” tag=”harlemworld-20″]Heart Failure Program[/easyazon_link] at MSSL to jointly deliver the best quality care to patients.”
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When health coaches reach patients within their own communities, they help fill gaps in care that patients might experience in between clinician visits.
Even some of the most high-needs patients still spend a majority of their lives outside of the hospital or the clinic office. Offering access to health coaches supports the idea of self-management during those times, said Cathleen Varley, a nurse practitioner at Mount Sinai St. Luke’s.
“The health coaches act, in essence, like a community extension of the care team,” Varley said in the statement. “They team up with their patients, to remind and empower them about the skills they have been taught, so they can manage their heart conditions on their own when the coaches aren’t there.”
Coaching sessions will cater to each individual patient, the two organizations explained. Patients might learn about how to manage their multiple medications, or how to monitor their weight or monitor their liquid intake. This individualized approach will be more meaningful for patients looking to improve their own health status and manage a specific chronic illness.
Additionally, health coaches will help provide insight into the social needs of patients, which are increasingly being recognized as key indicators of patient health. A health coach might discover that a patient cannot access transportation to her bi-weekly clinic visits, which can prompt hospital or community intervention.
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Overcoming these types of barriers are critical to successful chronic disease management, according to Mount Sinai St. Luke’s President Arthur Gianelli.
“This is just one example of the innovative, unique clinical work we are doing with Medicaid patients through DSRIP,” said Gianelli. “Partnerships with community-based organizations like City Health Works will help us better understand the social issues affecting patients’ health and improve care transition efforts. We look forward to developing similar programs with other organizations to tackle chronic conditions impacting our underserved populations.”
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