Wk 9 SOCW 8205 Discussion Discussion: Medical Social Work in Chronic Illness Care and Management Advances in medical technology have altered the trajectory of illness in our society. Many illnesses th

\bhat is health coac\nhing?

Health coaching ca\pn be \fefine\f as helpi\png patients gain the knowle\fge, skill\ps, tools an\f confi\fe\pnce to become active participants\p in their care so \pthat they can reac\ph their self\bi\fentifie\p\f health goals. The familiar a\fage \p“Give a man a fish,\p an\f he eats for a \fay. Teach a man \pto fish, an\f he eats\p for a lifetime,” \p \femonstrates the \fi\pfference between r\pescuing a patient an\f coaching a pati\pent. In acute care\p, rescuing makes sense: surgery for\p acute appen\ficitis \por antibiotics for\p pyelonephritis. For\p chronic care, pati\pents nee\f the knowl \b e\fge, skills an\f con\pfi\fence to participat\pe in their own care. Consi\fer the \pfollowing scenario\p: Mr. Olson has diabetes, hypertension and hyperlipide\fia. Despite seeing Dr. Ja\fes \bve ti\fes last year, he is confused about his six prescriptions. When he gave up eating candy, he thought that would solve so\fe of his proble\fs, so he stopped taking several \fedications. He uses his gluco\feter and brings his records to Dr. Ja\fes so she can tell hi\f what to do. He is frustrated when Dr. Ja\fes says his diabetes and cholesterol are still uncontrolled. Dr. Ja\fes is frustrated too. Dr. Ja\fes introduces Mr. Olson to Sue, a \fedical assis - tant trained as a health coach. Sue questions Mr. Olson on his \fost i\fportant life goals. She helps hi\f link his desire to avoid the a\fputation experienced by his brother to the i\fportance of taking \fedications. She teaches hi\f the skill of interpreting gluco\feter readings in relation to food, exer - cise and \fedications. Within three \fonths, Mr. Olson’s A1C drops fro\f 8.5 to 7. In Mr. Olson’s exa\pmple, rescuing mean\ps telling him what to \fo about hi\ps current glucomet\per rea\fings. Coach \b ing means helping h\pim un\ferstan\f an\f re\pact to his glu \b cose values, an en\p\furing skill that he\p can use every \fay.\p \bho can be a health\n coach?

Within the care te\pam, everyone can i\pntegrate elements \pof coaching into thei\pr interactions wit\ph patients. However\p, to ensure that coa\pching takes place, a\pt least one team member shoul\f be \fe\psignate\f as a coach\p. Health coaches can be nurses, soc\pial workers, me\fical\p assistants (MAs),\p community health w\porkers ( pro\fotores , for example), health e\fucators or\p even other patient\ps if given appropri \b ate training an\f su\ppport. 5,6 Registere\f nurses (\pRNs) are well poise\p\f to impart skills, buil\f confi\fe\pnce an\f provi\fe tool\ps for patients, particularly patien\pts \fischarge\f from \pthe hospital or wit\ph multiple chronic co\pn\fitions. Social wo\prkers are also well\p equippe\f for this ro\ple as they receive\p significant exposur\pe to coaching princip\ples \furing their tr\paining an\f often apply them in their\p work to promote pat\pient behavior change. However, s\pince RNs an\f social\p workers are rare in primary care offi\pces, MAs are often\p a goo\f choice for \p filling the role. W\phile their scope of\p practice prevents \p them from making me\p\fical assessments, \pMAs are i\feally suite\f to provi\fe li\pnguistically an\f cu\plturally concor\fant\p coaching. Working c\plosely with clinic\pians or RNs, they \p Article \beb Address: http://w w w.aafp.org/fpm/20\f00900/p2\b Downloaded from the Family Practice Management Web site at w w w.aafp.org/fpm. Copyright © 20\f0 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reser ved. Contac t [email protected] for copyright questions and/or permission requests. September/Oc tober 20\f0 | w w w.aafp.org/fpm | FAMILY PR AC TICE MANAGEMENT | 25 Health Coaching for Patients With Chronic Illness can a\f\fress me\ficati\pon a\fherence an\f li\pfestyle changes. No matter who serv\pes the coaching fu\pnction, coaching presumes a collabor\pative para\figm (aski\png patients what changes they are w\pilling to make) rat\pher than a \firectiv\pe para\figm (telling pa\ptients what to \fo).\p 7 A goo\f health coach un\ferstan\fs t\phis, grasps the shi\pft from rescuing to coaching, has a\p basic knowle\fge of \pcommon chronic con\fitions an\f me\fic\pations, an\f reliabl\py follows through \p to gain the trust \pof patients an\f cli\pnicians.

Speci\fc roles of a h\nealth coach Health coaching en\pcompasses five princ\pipal roles: 1) provi\fing self\bma\pnagement support, 2\p) bri\fging the gap between clinici\pan an\f patient, 3) \phelping patients navigate the healt\ph care system, 4) \poffering emotional\p support an\f 5) servi\png as a continuity\p figure (see “The five roles of a hea\plth coach” on page \p26). Providing self-manag\nement support. Self\bmanage \b ment support is ess\pential for patients\p to exten\f their health care outsi\fe\p the clinic walls \pan\f into their real\p lives. Coaches tra\pin patients in seve\pn \fomains of self\b management support:\p provi\fing informat\pion, teach \b ing \fisease\bspecific \pskills, promoting he\palthy behaviors, imparting problem\bso\plving skills, assis\pting with the emo \b tional impact of ch\pronic illness, prov\pi\fing regular follo\pw up an\f encouraging \ppeople to be active\p participants in their care. 2 Patients have bet\pter health outcome\ps when provi\fe\f with \fiseas\pe\bspecific knowle\fge a\pn\f skills. 7 A meta\banalysis of 53\p ran\fomize\f control\ple\f trials con \b clu\fe\f that self\bman\pagement support impr\poves bloo\f pressure an\f glucos\pe control. 8 Bridging the gap between clinician and patient. Throughout the care process, there are plenty of opportu \b nities for \fisconnects between the clinician an\f the patient.

Prescribing me\fications is one example. It is a two\bpart en\feavor: 1) writing prescriptions an\f 2) making sure patients obtain, un\ferstan\f an\f actually take the me\fica \b tions as prescribe\f. Physicians perform part one but lack time to a\f\fress the critical secon\f part. Health coaches can bri\fge these gaps by following up with patients, asking about nee\fs an\f obstacles, an\f a\f\fressing health literacy, cultural issues an\f social\bclass barriers. Helping patients nav\nigate the health c\nare system. Many patients, part\picularly the el\ferl\py, \fisable\f an\f 26 | FAMILY PR AC TICE MANAGEMENT | w w w.aafp.org/fpm | September/Oc tober 20\f0 marginalize\f, nee\f \pa navigator to hel\pp locate, negotiate an\f engag\pe in services. Coa\pches can help coor\finate car\pe an\f speak up for pa\ptients when their voices \pare not hear\f. Offering emotional su\npport. Coping with illness is em\potionally challeng\ping. Well\b intentione\f but rus\phe\f clinicians may \pfail to a\f\fress patients’ em\potional nee\fs. As t\prust an\f familiarity gro\pw, coaches can off\per emo \b tional support an\f h\pelp patients cope wi\pth their illnesses. Serving as a continu\nity \fgure. Coaches connect with patien\pts not only at offi\pce visits but also between v\pisits, creating fa\pmiliarity an\f continuity. Thi\ps is particularly h\pelpful in practices where cli\pnicians work part\bti\pme or see one another’s \ppatients.

Two models of healt\nh coaching The health coachin\pg role can be a\f\fe\f \pto a me\fical practice in\p a variety of ways\p, but two mo\fels have been pa\prticularly success\pful. The teamlet model . Pilote\f in 2006 a\pt the San Francisco \pGeneral Hospital Fa\pmily Health Center (FHC\p), the “teamlet” (\psmall team) mo\fel exten\fs\p the 15\bminute prima\pry care visit by seve\pral minutes, \fepen\fi\png on the patient, to inc\plu\fe coaching. In a\p teamlet, a physician is pair\pe\f with an MA or he\palth worker who has rece\pive\f training in se\plf\bman \b agement support an\f \pspecific chronic con\p\fi \b tions an\f speaks the\p language of the pa\ptients assigne\f to him or \pher. Health coache\ps con \b \fuct a pre\bvisit for\p me\fication reconci\pliation an\f agen\fa setting,\p assist \furing the \pphysician visit an\f, \furing a\p post\bvisit, assess\p whether patients un\ferstan\f \pan\f agree with the \prec \b ommen\fe\f care plan a\pn\f engage patients \pin behavior\bchange act\pion plans. Because \pregular follow\bup improves c\phronic \fisease outc\pomes, between\bvisit phone\p calls are use\f to \pcheck on action plans an\f me\p\fication a\fherence.\p 9\b12 In practice, the mo\p\fel looks something \p like this: Maria Rojas has hypertension, obesity, osteo - arthritis and poor eyesight. She and Dr. Lee used to feel overwhel\fed by her \fedical and acco\fpanying social proble\fs. Dr. Lee fre - quently ad\fonished her to take her \fedications, but Mrs. Rojas felt confused about her pills and never spoke up about it. When health coach Lisabeth was brought in to assist, Mrs. Rojas was skeptical but willing to participate. Lisabeth started by asking questions to better understand Mrs. Rojas’ concerns, instead of just telling Mrs.

Rojas to take her pills. Mrs. Rojas ca\fe to trust Lisabeth and, over ti\fe, beca\fe an active par - ticipant in her own care rather than si\fply a recipient of infor\fation. Now, a week after each physician visit, Lisa - beth calls Mrs. Rojas to ask whether she has picked up her prescriptions fro\f the phar\facy, to assess her understanding of how to take each \fedication and to encourage her to take the pills daily. Lisabeth always asks Mrs. Rojas to iden - tify barriers and solutions that \bt into her daily routines rather than doing this for her. She co\f - \funicates these barriers to Dr. Lee so that Mrs.

Rojas’ care plan can be readjusted as needed. Health coaches help patients gain the knowledge, skills and confi - dence to become active participant\0s in their care . Following up with patients, helping them navigate the system and of fering emotional suppor t are among the key responsibilities of a health coach.

THE FIVE ROLES OF A HEALTH COACH Self-management support Bridge between clinician and patient Navigation of the health care system Emotional support Continuity • Providing information • Teaching disease-specific skills • Promoting behavior change • Impar ting problem-solving skills • Assisting with the emotional impac t of chronic illness • Encouraging follow up • Encouraging par ticipation • Ser ving as the patient’s liaison • Ensuring that patient understands and agrees with care plan • Providing cultural and language-concordance • Connec ting the patient with resources • Facilitating suppor t • Empowering the patient • Ensuring the patient’s voice is heard • Showing interest • Inquiring about emotional issues • Showing compassion • Teaching coping skills • Providing familiarit y • Following up • Establishing trust • Being available September/Oc tober 20\f0 | w w w.aafp.org/fpm | FAMILY PR AC TICE MANAGEMENT | 27 H E A LT H C O A C H I N G The hospital-to-ho\nme model. Patients \fischarge\f from the\p hospital often fee\pl con \b fuse\f about their n\pew me\fications an\f \pthe con\fitions that the\py must now learn t\po man \b age. This makes the\pm excellent can\fi\fa\ptes for health coaching. T\phe Care Transition\ps Inter \b vention is a wi\fely\p\buse\f coaching meth\po\f that imparts skills, tool\ps an\f confi\fence to \ppatients an\f family caregive\prs as they move fr\pom hos \b pital to home. 13 It is focuse\f on “\pfour pillars” (http://www.caretra\pnsitions.org/struc\pture.asp): 1. Having a reliabl\pe me\fication manage\p \b ment strategy, 2. Overcoming barr\piers to follow\bup appointments, 3. Knowing how to \precognize an\f respo\pn\f to worsening signs\p an\f symptoms, 4. Using a personal\p health recor\f to r\pecor\f 30\b\fay goals, healt\ph information an\f ke\py questions to be sh\pare\f with the physi\pcian at upcoming health car\pe encounters. The Care Transitio\pns coach (nurse or\p social worker) visi\pts the patient once\p in the hospital an\f once a\pt home, an\f communi\p \b cates with the pati\pent three times by\p phone.

Here’s an example: Mrs. Lu\fpkin was ad\fitted to the hospital four ti\fes in the past three \fonths because of heart failure exacerbations. Each ti\fe, she required \fodest \fedication adjust\fent over two hospital days. Upon each discharge, she was given instructions and sent ho\fe. After her fourth ad\fission, she was enrolled in the Care Transitions Intervention. Her coach, Bernice, visited 48 hours after discharge and encouraged Mrs. Lu\fpkin to identify a health-related goal for the next 30 days. Without hesitation, Mrs. Lu\fpkin stated she wanted to attend her granddaughter’s soccer ga\fes. She ad\fitted \fissing these ga\fes for fear that her urinary incontinence would e\fbar - rass her and her granddaughter. When Bernice said, “Please show \fe your \fedications and how you take the\f,” Mrs. Lu\fpkin revealed she frequently skipped diuretics due to inconti - nence. They then realized that her read\fissions were related to untreated incontinence. Using her new personal health record, Mrs. Lu\fpkin wrote down questions for her physician about incontinence treat\fents and practiced asking the questions through a role-playing exercise to build con\bdence. Finally, Mrs. Lu\fpkin and Bernice reviewed signs and sy\fpto\fs of worsen - ing heart failure and how to respond. The low cost of th\pis mo\fel allows for\p a\fop \b tion in a wi\fe vari\pety of settings, a\pn\f the investment in coac\phing pays \fivi\fen\fs \p\fown \b stream in re\fuce\f h\pealth care costs. 13 The business case fo\nr health coaching in primary care Health coaching ha\ps been shown to pro\p\fuce promising clinical \pbenefits (see “A br\pief review of the health coac\phing literature” o\pn page 28). But the botto\pm line for private \ppractices or community healt\ph centers – both fi\pnance\f primarily by fees f\por clinician visit\ps – is, “Can we affor\f to a\f\f ext\pra me\fical assistan\pts to work as health coac\phes in our practice\ps?” Without payment ref\porm, the only way \p practices can justi\pfy the a\f\fe\f expense\p of health coaches is \pwith the a\f\fe\f clini\pcian pro\fuctivity that c\poaches can create.\p Three In the teamlet model, a physician is paired with a health coach who meets briefly with the patient before and af ter the physician visit.

Between-visit follow-up phone calls help to improve outcomes for patients with chronic diseases.

In the hospital- to-home model, a health coach visits the patient once in the hospital and once at home, and then follows up by phone. About the Authors Dr. Bennett is a resident in family medicine at the University of California, San Francisco (UCSF). Dr. Cole - man is director of the Care Transitions Program within the Divisions of Health Care Policy and Research and Geriatric Medicine at the University of Colorado Health Sciences Center in Denver, where he is also profes - sor of medicine. Dr. Parr y is assistant professor of medicine at the University of Colorado Health Sciences Center. Dr. Bodenheimer is professor of family and community medicine at UCSF. Dr. Chen is assistant clini - cal professor of family and community medicine at UCSF. Author disclosure: Drs. Coleman and Parr y receive suppor t from the John A. Har tford Foundation Inc. In ac\fte care, resc\fing makes sense\b For chronic care, patients need the knowledge, skills and confidence to participate in their own care\b 28 | FAMILY PR AC TICE MANAGEMENT | w w w.aafp.org/fpm | September/Oc tober 20\f0 examples exist of p\practices that have\p increase\f the me\fical assista\pnt:clinician ratio\p from 1:1 to 2:1, a ratio tha\pt provi\fes more tha\pn enough staff time for hea\plth coaching. Hilt\pon Family Practice, a private\p family practice in\p Newport News, Va., implemen\pte\f a care team wit\ph two clinical assis\ptants (nurses or m\pe\fical assis \b tants) per physicia\pn, allowing the phy\psician to \felegate substantia\pl work. This has in\pcrease\f visit volumes an\f c\pollections by 60 pe\prcent. 14 A BRIEF REVIE\b OF THE HEALTH COACHING LITERATURE Trials of health coaching, which can be identified by searching PubMed (ht tp://w w w.ncbi.nlm.nih.gov/pubmed) with the terms “coaching” or “coaches,” demonstrate mixed results on the ef ficacy of coaching on patient outcomes. The studies were heterogeneous regarding who per formed the coaching, the nature of the coaching inter vention and the chronic con - ditions studied. A summar y of findings is shown below:

Telephone coaching Patients receiving phone coaching from peer coaches were more likely to at tend colonoscopy visits. \f Dietitian or nurse coaches working via telephone achieved greater reduc tions in cholesterol and bet ter adherence to lipid-lowering drugs than usual care. 2 Telephone coaching of patients with acute coronar y syn - drome failed to improve smoking status, medication use or qualit y of life. 3 Diabetes coaching Patients with diabetes who received nurse coaching dem - onstrated bet ter self-repor ted diet compared with usual care but no significant dif ference in A\fC levels. \b Elderly adults with diabetes who received coaching improved physical ac tivit y levels; combining pedometer use with coaching did not improve results. 5 African-American adults with diabetes who had peer coach - ing by community health workers had nonsignificant reduc - tions in A\fC levels compared with those who had usual care. 6 African-American and Latino adults with diabetes coached by trained communit y residents had significant declines in A\fC levels compared with a control group. 7 Asthma coaching Communit y health workers trained as asthma coaches reduced asthma rehospitalization among African-American children compared with a control group. 8 Hospitalized patients receiving post-discharge assistance from a “transition coach” were significantly less likely to be rehospitalized than control patients. 9 A Cochrane Review of peer-led coaching for patients with chronic conditions found small but statistically significant reduc tions in pain, disabilit y and depression in the inter - vention group. \f0 A randomized controlled trial of medical assistants coach - ing patients with depression in primar y care prac tices found a significant improvement in patients with coaches compared with usual care. \f\f \f. Turner BJ, Weiner M, Berr y SD, Lillie K, Fosnocht K, Hollenbeak CS. Overcoming poor at tendance to first scheduled colonoscopy: a randomized trial of peer coach or brochure suppor t. J Gen Intern Med . 2008;23:58- 63. 2. Vale MJ, Jelinek MV, Best JD, et al. Coaching patients on achiev - ing cardiovascular health (COACH): A multicenter randomized trial in patients with coronar y hear t disease. \frch Intern Med. 2003;\f63:2775-2783.

3. Holmes-Rovner M, Stommel M, Corser WD, et al. Does outpa - tient telephone coaching add to hospital qualit y improvement fol - lowing hospitalization for acute coronar y syndrome? J Gen Intern Med. 2008;23:\f\b6\b-\f\b70. \b. Whit temore R, Melkus GD, Sullivan A, Grey M. A nurse-coaching inter vention for women with t ype 2 diabetes. Dia\betes Educ . 200\b;30:795-80\b.

5. Engel L, Lindner H. Impac t of using a pedometer on time spent walking in older adults with t ype 2 diabetes. Dia\betes Educ. 2006;32:98-\f07.

6. Gar y TL, Bone LR, Hill MN, et al. Randomized controlled trial of the ef fec ts of nurse case manager and communit y health worker inter ventions on risk fac tors for diabetes-related complications in urban African Americans. Prev Med . 2003;37:23-32. 7. Two Feathers J, Kief fer EC, Palmisano G, et al. Racial and ethnic approaches to communit y health (REACH) Detroit par tnership: improving diabetes-related outcomes among African American and Latino adults. \fm J Pu\blic Health . 2005;95:\f552-\f560. 8. Fisher EB, Strunk RC, Highstein GR, et al. A randomized con - trolled evaluation of the ef fec t of communit y health workers on hospitalization for asthma: the asthma coach. \frch Pediatr \fdolesc Med . 2009;\f63:225-232. 9. Coleman E, Parr y C, Chalmers S, Min S. The Care Transitions Inter vention: results of a randomized controlled trial. \frch Intern Med. 2006;\f66:\f822-\f828. \f0. Foster G, Taylor SJC, Eldridge SE, Ramsay J, Grif fiths CJ. Self-management education programmes by lay leaders for people with chronic conditions. Cochrane Data\base Syst Rev. 2007;\f7(\b):CD005\f08.

\f\f. Gensichen J, von Kor f f M, Peitz M, et al. Case management for depression by health care assistants in small primar y care prac tices. \fnn Intern Med. 2009;\f5\f:369-378. September/Oc tober 20\f0 | w w w.aafp.org/fpm | FAMILY PR AC TICE MANAGEMENT | 29 H E A LT H C O A C H I N G Their approach \foes \pnot involve formal\p health coaching but \foes \f\pemonstrate the pote\pntial for increase\f pro\fuc\ptivity with the a\f\f\pition of an assistant. N\peighborhoo\f Healthc\pare, a community health c\penter near San Die\pgo, increase\f the me\fic\pal assistant:physic\pian ratio from 1:1 to 2:1, wit\ph the me\fical assis\ptants performing some coa\pching functions. T\phis has allowe\f the phy\psicians to see two\p to three more patients per \fa\py, which pays for t\phe a\f\fitional me\fical a\pssistants. Similar\ply, the University of Utah\p Hospitals an\f Clin\pics health system emplo\pys extra me\fical as\psistants to streamline physi\pcians’ work. As a r\pesult, pro\fuctivity has in\pcrease\f an\f the hea\plth system’s financial \pposition has improv\pe\f \framatically. 15 These three case s\ptu\fies \femonstrate \pthat a business case ca\pn be ma\fe for hirin\pg me\fi \b cal assistants to \pfunction as health\p coaches. In many cases, the me\p\fical assistant:cli\pnician ratio woul\f not nee\p\f to be as high as \p2:1, as in the examples abo\pve. For example, on\pe health coach (pai\f \p$15 per hour or $36,\p000 per year with benefi\pts) coul\f assist th\pree phy \b sicians, since onl\py a fraction of pat\pients nee\f coaching. Each phys\pician woul\f nee\f to\p see two extra patients \pper \fay at a reimbu\prsement rate of $40 per vis\pit to generate $57,\p600 in a\f\fitional revenue,\p more than enough \pto pay for the health coa\pch.

Paradigm shift Health coaching is\p both a conceptual \pframe \b work an\f a concrete \pjob category with \pthe potential to improv\pe patient care an\f \passist clinicians struggl\ping with insufficie\pnt time. Coaching involves a para\figm shift from a \firective to a collaborative mo\fel so that care teams an\f patients pursue an active partner \b ship, instea\f of patients being passive recipi \b ents of care. I\feally, everyone on the health care team woul\f incorporate coaching in their work. Yet, to ensure that coaching happens reliably, specific team members can be \fesig \b nate\f to be health coaches. While physicians are well\btraine\f to “give patients a fish” – cur \b ing an acute problem or prescribing me\fica \b tions for a chronic con\fition – health coaching teaches patients an\f families “how to fish.” Send comments to fpm\fdit\baafp.org. \f. Østbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of patients with chronic diseases in primar y care? \fnn Fam Med . 2005;3:209-2\f\b.

2. Bodenheimer T. A 63-year-old man with multiple car - diovascular risk fac tors and poor adherence to treatment plans. J\fM\f . 2007;298:20\b8-2055. 3. Braddock CH, Edwards K A, Hasenberg NM, Laidley TL, Levinson W. Informed decision making in outpatient prac - tice. J\fM\f . \f999;282:23\f3-2320. \b. Haynes RB, McDonald HP, Garg A X. Helping patients follow prescribed treatment: clinical applications. J\fM\f . 2002;288:2880 -2883.

5. Brownson CA, Heisler M. The role of peer suppor t in dia - betes care and self-management. The Patient . 2009;2:5-\f7. 6. Holland SK, Greenberg J, Tidwell L, Newcomer R. Pre - venting disabilit y through communit y-based health coach - ing. J \fm Geriatr Soc . 2003;5\f:265-269. 7. Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primar y care. J\fM\f . 2002;288:2\b69-2\b75. 8. Chodosh J, Mor ton SC, Mojica W, et al. Meta-analysis: chronic disease self-management programs for older adults. \fnn Intern Med . 2005;\f\b3:\b27- \b38. 9. Bodenheimer T, Laing BY. The teamlet model of primar y care. \fnn Fam Med . 2007;5:\b57- \b6\f. \f0. Training Curriculum for Health Coaches . San Francisco: Center for Excellence in Primar y Care; 2009. ht tp://w w w.ucsf.edu/cepc.

\f\f. Handley M, MacGregor K, Schillinger D, Sharifi C, Wong S, Bodenheimer T. Using ac tion plans to help pri - mar y care patients adopt healthy behaviors: A descriptive study. J \fm Board Fam Med . 2006;\f9:22\b-23\f. \f2. Laing BY, Ward L, Yeh T, Chen E, Bodenheimer T. Intro - ducing the “teamlet”: initiating a primar y care innovation at San Francisco General Hospital. The Permanente Jour - nal. 2008;\f2:\b-9. \f3. Coleman E, Parr y C, Chalmers S, Min S. The Care Tran - sitions Inter vention: results of a randomized controlled trial. \frch Intern Med. 2006;\f66:\f822-\f828. \f\b. Anderson P, Halley MD. A new approach to making your doc tor-nurse team more produc tive. Fam Pract Manag. July/August 2008:35- \b0. \f5. Bodenheimer T. Building Teams in Primary Care: 15 Case Studies . Oakland, Ca: California HealthCare Founda - tion; July 2007. ht tp://w w w.chc f.org. The increased physician produc - tivity that health coaches create can of fset their costs.

If one health coach (MA) assists three physicians, each physician would need to see two extra patients per day to cover the costs.

Coaching involves a paradigm shif t from a directive to a collaborative model of care. The bottom line is, “Can we afford to add extra medical assistants to work as health coaches in o\fr practices?” Copyright of Family Practice Management is the property of American Academy of Family Physicians and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.