Planned and Mini-Group Medical Visits (January 10, 2013)
This presentation by Dr. Devin Sawyer, Program Director, St. Peter Family Medicine Residency Program, as part of the Safety Net Medical Home Initiative, goes into considerable detail on the role of medical assistants in planned care for patients with chronic illness, as well as the use of group visits by the practice to make care more efficient and effective. It includes details on E&M Billing codes used by the practice related to MA-centric planned visits and their diabetes group vist model.
Health Coaching in the Teamlet Model: A Case Study
This article provides a case study of health coaching provided within a stable provider-health coach teamlet model at San Francisco General Hospital's Family Health Center. In this model, health coaches are medical assistants and community health workers. Ngo, V, Hammer, H, Bodenheimer, T. Health Coaching in the Teamlet Model: A Case Study. J Gen Intern Med. Dec 2010; 25(12): 1375–1378. PMCID: PMC2988157.
Using the Teamlet Model to Improve Chronic Care in an Academic Primary Care Practice
Chen, EH, Thom, DH, Hessler, DM, Phengrasamy, L, Hammer, H, Saba, G, Bodenheimer, T. Using the Teamlet Model to Improve Chronic Care in an Academic Primary Care Practice. J Gen Intern Med. Sep 2010; 25(Suppl 4): 610_614. PMCID: PMC2940441.
Case summariesVignettes, profiles and testimonial videos
Self-Management Support at High Plains Community Health Center
Learn how one LEAP site developed a comprehensive chronic disease program to provide patients with self-management support. Health Coaches are a central part of the comprehensive support at High Plains Community Health Center to help patients make and progress towards their health goals.
ToolkitsImplementation guides and other documents with extensive resources included
Partnering in Self-Management Support: A Toolkit for Clinicians
This toolkit was developed by the Institute for Healthcare Improvement as part of New Health partnerships: Improving Care by Engaging Patients. It is designed to give busy clinical practices an introduction to a set of activities that support patients and families in the daily management of chronic conditions. Registration on IHI's site is required before the toolkit can be downloaded, but it is free to register.
The Flinders Program consists of a set of tools that are completed by the client and the health care worker as a team. Its goal is to provide a systematic, evidence-based approach to assessing self-management capacity and assisting care planning for individuals with chronic illnesses. It includes a questionnaire, a structured interview to explore responses in more depth, and ultimately a care plan. Produced by the Human Behaviour & Health Research Unit at Flinders University in Australia.
Chronic Disease Self-Management Program (Better Choices, Better Health Workshop)
The Chronic Disease Self-Management program was developed by investigators at Stanford University's School of Medicine in the 1990s, and it has become one of the most widely disseminated self-management support programs in the world. It consists of six workshop sessions, attended by individuals with a variety of chronic illnesses, and facilitated by non-health professionals who themselves have chronic diseases.
This website offers various resources on motivational interviewing, maintained by the Motivational Interviewing Network of Trainers. Click on the link to see a list of upcoming in-person courses. There is also a link to online courses, when available.
Basic Skills and Clinical Applications of Motivational Interviewing
This online course is intended to train primary care practice staff seeking PCMH certification in the principals of motivational interviewing. It consists of two 30-minute modules on using MI to help patients change health behaviors, as well as providing scenarios in how the concepts can be used in the clinical setting. It is CME/CE certified, and is described on the site as a free service once site registration is completed.
The UCSF Center for Excellence in Primary Care (CEPC) offers a comprehensive variety of health coaching training materials, including action plans, role play scenarios, and protocol. You can also download their entire health coaching curriculum, which has demonstrated success in training up MAs to be health coaches in a randomized controlled trial.
Patient Navigator Certificate Program Goals and Objectives
This single page document lays out the Goals and Objectives of the Sonoma State University Patient Navigator Certification Program and identifies the core components of the role and the skill set that needs to be learned to succeed as a Patient Navigator.
Self-Management Support Training for Medical Assistants
Union Health Center developed a robust training curriculum for MAs to take on expanded roles in patient education. Self-management support is a major component of the training, including goal setting, reflective listening, motivational interviewing, and relationship-building. The MA curriculum consists of PowerPoint slides, in-person exercises, and homework assignments. To receive a pdf of the MA training curriculum, please contact Audrey Lum, RN, MPA, at firstname.lastname@example.org
Role featuresJob descriptions, career ladders and other HR materials
Patient Navigator Job Description
This Position Description from West County Health Centers summarizes the role of the Patient Navigator as an advocate for high-need and high-risk patients, describes the duties performed by the position, and the minimum requirements for filling the role.
Flowsheet for Medical Assistant Diabetes Management (MADM) Visit
This flowsheet for the Medical Assistant Diabetes Management (MADM) visit steps through the identification, scheduling, and order review steps that occur before the visit, as well as the actions to be conducted in the visit itself.
See how one LEAP site has added several templates into the EHR in order to effectively provide self-management support to patients. There are fields for patient goals that are regularly used by care team members, especially providers and health coaches.