Frequent fliers who come into the ED for preventable, non-urgent care needs are among the costliest and most difficult patients to treat. Such patients often have chronic illnesses which are compounded by lifestyle factors such as a lack of access to transportation, healthy food, and knowledge about the health care system.
Successfully treating these patients requires a robust primary care network that activates patients before they reach the hospital, as well as coordination with community organizations to address health illiteracy and non-clinical health issues. The Bon Secours Life Coach program provides one model designed to help such patients navigate the health care system. The program dedicates several hospital staff members called Life Coaches to helping high-risk, underinsured patients get the primary and preventative care they need.
What is the Bon Secours Life Coach Program?
The program was initiated at Bon Secours DePaul Medical Center, where two Life Coaches work in the ED to improve health outcomes for high-risk patients and prevent costly and inappropriate trips to the ED. Patients who meet certain eligibility criteria are flagged in the Electronic Health Record (EHR); Life Coaches then use face-to-face interviews and follow-up telephone calls to connect these patients to the appropriate primary and preventative care resources.
To increase primary care capacity, Bon Secours has partnered with Park Place Medical Center, a local Federally Qualified Health Center (FQHC). Park Place has extended its hours so that patients who cannot come in during normal business hours due to job restrictions or transportation issues can be seen after-hours.
The Life Coach program has seen considerable success thus far. Out of 1,000 patients who participated in the program in 2009, only 12 returned to the ED for a primary care need. Additionally, 90% of the patients connected with primary care actually attended their appointments.
What does the Life Coach do in the ED?
Life Coaches are available to patients Monday through Friday from 7 a.m. to 8 p.m. At registration, patients are asked about their insurance enrollment status and whether or not they have a regular primary care physician. The EHR flags patients without insurance or a physician, alerting the Life Coaches to their presence.
Once notified, Life Coaches work with the ED team to determine the most appropriate time to speak to the patient. For example, this may be after the patient has received treatment but while they are waiting for test results.
The Life Coach then meets with the patient for a 30-minute face-to-face interview. The interview assesses both physical and social needs, including smoking status, nutritional habits, and access to transportation.
Following the interview, the Life Coach refers the patient to either Park Place Medical Center or the Bon Secours employed Medical Group to establish ongoing primary care, as well as to relevant community organizations for additional support. The Life Coach also follows up with patients by phone a few days after discharge to help encourage appointment attendance and ensure that patients are taking the necessary next steps in their care plan.
If a patient comes to the ED after hours (i.e., on a weekend or between 8 PM and 7 AM on a weekday), Life Coaches are alerted the next business day. The Life Coach then contacts the patient by phone to perform the same 30-minute interview and referral process to establish an ongoing site for primary care.
Health Care Advisory Board members, download the white paper to learn more about Bon Secours Life Coach program. Get sample job descriptions, an interview checklist, and more. Not a member? Learn more on our website.