An Inter-professional Approach Health Coach Model to Reduce the Risk of Coronary Events in Diabetic Patients - April 15, 2021
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Stup, MPH, Emmy; Perez, MEd, Sandra; Dougherty, PharmD, Tanya; and Ward, MD, MPH, FACP, Lawrence D., "An Inter-professional Approach Health Coach Model to Reduce the Risk of Coronary Events in Diabetic Patients - April 15, 2021" (2021). Know Diabetes by Heart and Diabetes INSIDE Shared Learning. Paper 5.
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.
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:
Future Plans: Ongoing quality improvement and goals
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