We know that not all patients need the same intervention. A unique feature of the Health Coach care management program is the strategic identification of patients who will benefit. Rather than a traditional referral program, we will be Case Finding based on Reports and Registries, which combine clinical and claims based data and utilize predictive analytics.
Each Health Coach regularly receives updated, current lists of patients that have been risk stratified and identified as high risk, attributed patients to reach out to and manage. The Health Coaches are responsible for monitoring and interacting with these patients only. In order to meet expectations of care team volumes and be successful in our collaborative care management efforts, our focus must remain on these patients.