Health Coaching can be defined as helping patients gain the knowledge, skills, tools, and confidence to become active participants in their care so they can reach their self-defined SMART goals.

SMART stands for:

S: Specific

M: Measurable

A: Attainable

R: Relevant

T: Time-bound

Psychiatric Collaborative Care Management (PsychCoCM)

The Psychiatric Collaborative Care Model (PsychCoCM) is a mental health program that supports primary care. The team consists of a primary care physician (PCP), a behavioral health care manager, and a psychiatric consultant. The care team uses proactive, systemic assessments and validated rating scales to provide a robust and integrative treatment plan for the patient. Our team assists the primary care team with diagnosis, treatment planning, and recommendations about changes in treatment. If the patient is not at least 50% improved after 10-12 weeks on any given treatment plan, appropriate referrals to a higher level of care are made.

2020 P3N Data

Chronic Care Management (CCM)

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The Chronic Care Management (CCM) is designed to assist and support patients along their care plan. This program creates a structured engagement between the Health Coach and the patient in order to periodically assess the health status of the patient using standardized and validated surveys that can be quantified and captured sequentially. For those patients with more complex cases, we use specialty educators such as diabetic educators, nutritionists, respiratory therapists, and registered nurses to provide extra support and guidance.

Our CCM program provides a dedicated health coach who will partner with patients to ensure they receive coordinated care. Each month, at least 20 minutes of clinical staff time is devoted to managing the patient. A personalized care plan that supports the day-to-day management of their conditions is created for each patient.

Our CCM program focuses on many disease paradigms including:

  • Diabetes Mellitus/Obesity (Weight Management Program)
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Asthma
  • Hypertension
  • Congestive Hearth Failure (CHF)
  • Obstructive Sleep Apnea and Sleep Hygiene

Remote Physiologic Monitoring (RPM)

The Remote Physiologic Monitoring (RPM) program utilizes a subset of telehealth that facilitates the monitoring, as well as, the timely transfer of patient-generated physiologic data points back to the patient care team. Using this data, often in conjunction with our CCM program, we create unique clinical pathways for multiple chronic conditions including hypertension, CHF, obesity, diabetes mellitus, COPD, and others. Current devices supported include a BP cuff, weight scale, and pulse oximeter.

Services in development:

  • Glucose monitoring for diabetes
  • Activity and gait monitors for neurodegenerative diseases (Parkinson’s, MS, Frail Elderly)

*Coming Soon*

Pharmacy Collaborative Care Management (PharmCoCM)

The Pharmacy Collaborative Care Management (PharmCoCM) program allows pharmacists, using protocol treatment guidelines, to participate in the practice, of ordering, managing, and modifying medication therapy. It allows pharmacists to use their unique skills and abilities to complement other types of care provided by collaborating professionals to optimize patient outcomes.

Treatment protocol guidelines will include:

  • Hypertension
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Asthma
  • Lipids
  • Congestive Hearth Failure (CHF)
  • Diabetes and Obesity
  • Chronic Opioid Use
  • Depression/Anxiety

Frail Elderly Initiative

Our Frail Elderly Initiative aims to use our health coaching models to engage high risk with reduced physiologic reserve whom are vulnerable to external stressors. Our program will use standardized surveys and evaluations to assess physical ability/activity, cognitive function, and mood state with the objective of improving those measures through a patient-specific care plan. This care plan may include such services as medication management, remote physical therapy, and/or psychiatric collaboration.