An Inter-professional Approach Health Coach Model to Reduce the Risk of Coronary Events in Diabetic Patients - April 15, 2021

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In this session speakers from the interdisciplinary quality improvement team at Jefferson Internal Medicine present their project focused on reducing the risk of coronary events in patients with diabetes.

Project description: This project employs a multidisciplinary health coaching model to address the complex barriers that impede achievement of optimal health outcomes for patients with uncontrolled diabetes. The patient-facing component utilizes health coaching (medical and behavioral aspects) and targeted referrals (e.g., specialists in lifestyle modification, behavioral health, continuing care, pharmacy). The provider-facing component utilizes a combination of validated tools, targeted education (e.g., lipid management), and periodic feedback.

Preliminary results:

The pandemic created additional challenges to patient engagement (e.g., lack of on-site enrollment at the clinic). Since October 2020, the program enrolled 53 patients, 25 of whom achieved control of their hypertension and 10 improved their hypertension status. An FCC grant made it possible to provide blood pressure cuffs to patients for remote monitoring. Early outcomes:

  • Statin prescribing for patients with diabetes increased by 7% (approximately 150 patients).
  • A statin choice decision aid embedded in the EHR was used more frequently; statin quality measure improved by 8%.

Future Plans: Ongoing quality improvement and goals

  • Continue to identify high-risk patients eligible for coaching
  • Address pandemic-related and other barriers to patient engagement (e.g., leverage online tools for providing health coaching)
  • Continue to monitor clinician use of tools for managing statins


Emmy Stup, MPH
Director of Practice Transformation and Value-Based Care

Sandra Perez, MEd
Practice Transformation Coordinator and Health Coach

Tanya Dougherty, PharmD
Population Health Pharmacist

Lawrence Ward, MD, MPH, FACP
Professor of Medicine
Professor, Jefferson College of Population Health
Executive Vice Chair, Jefferson Health
Vice Chairman for Clinical Practice and Quality, Jefferson Health


Gregory S. Liptak
Vice President, Quality Improvement Services
American Diabetes Association

Presentation: 41:31



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