Integrate Health Coaches into the Care Team

Play Strategy
What is a Play? Box

Evidence has shown that health coaching can help patients improve their health. Health coaching helps patients build the knowledge, skills, and confidence required to manage their chronic conditions. Health coaches empower patients to play a central role in clinical encounters and to engage in self-management activities at home, work, and school, where they spend most of their lives. Therefore, health coaching can play an especially important role for patients with complex needs, who may struggle to manage multiple conditions,  providers, and services outside the health system. Training staff in evidence-based practices can help them engage patients in co-created care plans, promote good communication about diagnoses and treatment, and follow up with patients.

The goal of this Play is to engage patients and families in person-centered co-design and to develop your care model.

Play: health coaching
Play: health coaching
How to run the Play
  1. Identify members of the primary care team who can spend some time as health coaches.
  2. Establish “teamlets,” or small teams, of a clinician and a health coach working together to extend the primary care visit.
  3. Train the entire practice on health coaching, using the University of California San Francisco Center for Excellence in Primary Care curriculum or another training tool.
  4. Integrate health coaching into the practice, checking in at regular intervals to improve the health coach training and role in the practice.
Tips and tricks
  • Anyone on the health care team can serve as a health coach or use health coaching skills. But many practices find it helpful to train non-clinical staff, such as medical assistants and community health workers, to act as health coaches in order to free up primary care providers’ limited time. 
  • It’s important to train not just health coaches, but rather the entire team. Training the full practice helps ensure team members know how to work with health coaches effectively and that patients receive a coordinated message about the role of health coaches.
  • The “teamlet” (small team) model is just one way to incorporate health coaching. If you’re not able to implement this model, be sure to review the training material on health coaching to see which aspects of the model are possible for you to implement.
  • Health coaches may attend some or all of the steps in a visit. They can meet with the patient before the visit to establish goals as part of the patient’s coordinated care plan, attend the visit to help the patient and hear the provider’s guidance, review the visit with the patient after it concludes, and follow up with the patient in between visits.
  • Embrace the spirit of health coaching, which is that effective care requires collaboration between patient and provider, not a hierarchical approach where the provider assumes authority over the patient.
  • Be sure to rehearse some of the concrete skills health coaches can use, such as ask-tell-ask, closing the loop, and developing Brief Action Plans.
For More Information

This play was developed by the Institute for Healthcare Improvement (IHI) based on their work in the Better Health and Lower Costs for People with Complex Needs collaborative, which ran from 2014-2017.