BMS Health Coaches touch on SDOH tasks:


The Health Coach will work cooperatively with nursing staff to achieve patient outcomes and goals. The primary responsibility includes implementing a collaborative process of data collection for the Health Home At-Risk project and Health Home eligibility, care planning, facilitation of population health management, coordination of care for patients on caseload, patient education, patient advocacy, and regular evaluation of patients on caseload.

Uses registries to identify patients with newly diagnosed, undiagnosed or poorly controlled chronic conditions and schedules follow-up appointments.

Conducts outreach to patients with overdue screenings or upcoming appointments.

Performs intake and social data collection of patients with newly diagnosed or poorly controlled chronic conditions, screens for Health Home eligibility, and checks Health Home enrollment.

Screens for behavioral health and substance use problems, including depression (PHQ), alcohol abuse (AUDIT), substance abuse (DAST) and smoking status.

Reinforces education provided by PCP or nurse on management of the chronic disease, provides self-management tools, and reviews how to use those tools.

Does post-visit review of next steps with patient. With the patient, establishes goals and creates a care plan. Works with patient to mitigate impacts of social factors on health and functional status, e.g. by arranging transportation for patients.

Coordinates care, assists with referral management, and conducts between-visit monitoring & Outreach.

Tracks and follows up on test results to ensure patient and caregiver take appropriate next steps as needed. Serves as primary care practice’s first point of contact during post discharge care transition from hospital or emergency department.

Documents activities in EHR/GSI Health Dashboard. Works with Coordinator of Value Based Initiatives and practice’s performance improvement team. Assists in scheduling huddles and other internal team meetings.

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