Community Health Coach

Job Description

The Coordinating Center is recruiting Health Coaches residing in Anne Arundel County. This position will require maximum flexibility to meet with clients in their homes following discharge from a hospital. AA degree in health or human services, home visit work experience and a strong understanding of individuals with complex medical needs required. Orientation in our Millersville office is required but health coaches will transition to working from home with many remote meeting/training options; mileage reimbursement, comprehensive benefits package and an opportunity to work in a team environment to successfully manage the healthy outcomes of adults.

Background: The primary goal of the Health Coach is to reduce hospital readmissions for high risk patients. The Coordinating Center works closely with the Aging and Disability Resource Center as a referral source to assist with access to public programs and services that support a persons ongoing health and wellness.

Position Description and Responsibilities: The Health Coach functions as a facilitator of interdisciplinary collaboration and care continuity across care settings, specifically hospital to home, coaching the patient and family/caregiver to play an active and informed role in care plan design and execution.

Patients are identified in the hospital and after discharge assigned to a Health Coach for a home visit to occur within 72 hours of discharge. The home visit is guided by the use of the Coleman Transition Intervention and identification of a clients personal goal for remaining out of the hospital. This is followed up with telephonic communication and, if necessary. additional home visit.

The Health Coach collaborates with patients/caregivers to build confidence in four conceptual areas, or pillars-

Medication self management: Assist patient/family caregiver in comparing discharge medications to current and old medications, and identify and record medication discrepancies in the PHR for clarification with PCP.

Use of a patientcentered record (personal health record or PHR): Assist client in utilizing PHR to document pertinent medical information and questions for follow up appointments.

Primary Care and Specialist Follow Up: Make sure clients have scheduled a follow-up appointment, or assist in setting one up and ensure they have access to this appointment.

Knowledge of Red Flags: Review patients understanding of his/her conditions and symptoms and what actions to take when symptoms arise before the situation becomes emergent.

Additional Responsibilities include:

Facilitate the transition of patients to the home (or identified discharge location) using principles consistent with the Coleman Model for care transition.

Identify resources or additional programs to address barriers identified by the patient.

Collaborate with hospital discharge teams, hospitalists, community physicians and other providers to support a smooth and effective transition to home.

Promote self-care management in order to prevent avoidable hospital readmissions.

Follow progress of high risk patients, providing home visits and follow up phone calls.

Model communication for patients with post-acute care providers to ensure best practice measures are followed.

Work collaboratively with the local Aging and Disability Resource Center to refer clients for public services and programs available.

Facilitate resolution of problems as related to health and safety of the client.


To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skills, and/or abilities required:

Associates Degree (AA) or Bachelor's Degree (B.A.) preferred in health/human services or related field.

Two years related experience and/or training and working knowledge of housing, social service and individual support services; Medicare/ Medicaid services or Home and Community Based Waivers is desirable.

Experience in coordinating community based services.

Experience in the elements of care transitions desired.

Cultural sensitivity and ability to communicate effectively with individuals with varied cognitive abilities to establish relationships.

Ability to speak effectively with clients, partners and co-workers of the organization.

Ability to read and interpret documents such as hospital discharge paperwork, assessment reports or medical records, and procedure manuals.

Ability to document effectively in CARMA software care management system.

Ability to travel throughout the state of Maryland estimated to average at least 50% of work schedule.

In addition to the above qualifications the successful incumbent is expected to consistently demonstrate:

Positive working attitude that supports the needs of the care transition team.

Support of the mission and values of The Coordinating Center with a commitment to a person-centered, family-centered, culturally competent philosophical base.

Commitment to continuous quality improvement working with co-workers in a team oriented collaborative governance model.

Flexibility and the ability to adapt to the changing healthcare environment and legislation.


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