Care Transformation Center Blog

Health coaches vs care managers: Do you need one or both?

Cabell Jonas

A member recently asked us what the difference is between a health coach and a care manager. Currently, care management staff names are not standardized across health systems. Although the health coach and high-risk care manager both practice in the outpatient arena, they have distinct job duties and interact with different types of patients.

To help determine which role is right for your organization, read our definitions below and use our recently launched care management Staff Audit Tool.

Health coaches: Panel management and monitoring

A health coach is embedded in primary care and manages a wide range of patients within panels, acting in a generalist role.

Job duties are focused on fulfilling preventive care needs, managing patients with chronic conditions, and flagging at-risk patients in need of attention, such as bringing in diabetics in need of an HbA1c screening.

The case load for health coaches varies based on whether there are other care managers within the clinic. For example, if the clinic also has a high-risk patient care manager, the health coach would focus on lower-risk patients.

When could you benefit from a health coach?
If your organization is focused on hitting quality metrics for entire primary care panels, consider hiring a health coach.

At Mercy Clinics, a RN health coach proactively manages a disease registry, reaches out to bring in patients for preventive screenings, and engages chronically-ill patients in self-management. The goals of these activities are closely aligned to the preventive care and quality targets within contracts, or that the organization has prioritized.

Mercy Clinics earns additional revenue from these preventative care and disease management services, which improves practice economics and helps clinics hit quality metrics and attain quality bonuses. This revenue can also offset the health coach salary, making this a cost-effective approach.

High-risk care managers: Focusing on the highest-risk patients

The high-risk outpatient care manager is also embedded in primary care, but only manages the riskiest and costliest patients—typically the top 5-10% of a given panel.

A high-risk outpatient care manager only interacts with a subset of very complex patients who typically have multiple chronic illnesses, behavioral health comorbidities, and complex social needs. Job duties are focused on coordinating care across the entire care continuum, advancing care plan progress, providing ongoing patient self-management support, and fulfilling other complex needs as they arise.

The case load for high-risk outpatient care managers is highly dependent on experience, and ranges from 40-250 patients (250 patients is on the extremely high side, but is attainable with care managers that have 20+ years of experience).

When could you benefit from a high-risk care manager?

When seeking to reduce total cost of care for a defined population, consider hiring a high-risk care manager. These managers can engage with patients in the ambulatory setting to better manage chronic illness and mitigate avoidable utilization in higher-acuity care settings, which is critical for succeeding under new payment contracts.

As systems evolve, so might care management needs

Many organizations established health coach roles during medical home rollout to proactively manage entire patient panels. As care delivery systems evolve, organizations are providing specific high-risk patient resources, either in tandem with existing coaches or as a first step to capture value under risk-contracts.

Organizations at various stages may find that both positions work well together to manage comprehensive care needs across a population.

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