Why Add Coaching and Care Coordination to Chronic Care Management?

Patients with multiple chronic conditions have complex needs, and they are among the most challenging patients for a primary care practice to manage. One solution being adopted by practices to address this challenge is non-face-to-face care coordination—motivating and coaching patients through a comprehensive plan of care that covers physical, functional, social, financial, and behavioral goals.


But does this form of health coaching work? Although large-scale, well-designed studies on this relatively new addition to primary care resources are lacking, there is evidence that the answer is yes.


A new white paper presented by the head of nursing for Quest Chronic Care Management services, explores this topic. Should Your Practice Add Care Coordination and Coaching to Chronic Care Management? offers data that supports the use of coaching in healthcare.


The role of health coaches in chronic care management

Health coaches and other types of care coordinators—typically nurses or allied health professionals—contact patients monthly between office visits. Coaches motivate patients to follow treatment protocols and take more responsibility for their own health, while also providing information back to the practice. Coaching activities vary based on patient demographics.


For patients over the age of 65, for example, care coordination includes helping them keep track of their medications and stick to diet and exercise recommendations. It also involves coordinating care with other providers besides the primary care practice. In this way, health coaches act as intermediaries to help improve patient adherence, the patient experience, and, ultimately, health outcomes.


A recent phenomenon for medical practices

Health coaching itself is not new. It has been utilized by health plans and disease management companies for years. For medical practices, however, the addition of health coaching to their services is a recent phenomenon, and it seems to be working.


Data supports this, suggesting that health coaching can lead to improved outcomes, economics, and clinician experience. For example, in a study published in Families, Systems & Health, clinicians rated visits with health-coached patients as less demanding and were more likely to feel that they had adequate time with those patients compared with usual-care patients.1


Researchers in the Families, Systems & Health study (Dubé K, et al.) conducted interviews to learn more about how health coaching contributed to positive results. They concluded that in working with patients between medical visits, health coaches empower patients to self-manage, bridge communication gaps between clinicians and patients, help patients navigate the healthcare system, and serve as a point of contact between healthcare providers and patients.1  Download the coaching and chronic care management white paper to learn more.


A service that can help

For patients with multiple chronic conditions enrolled in Medicare, the Centers for Medicare & Medicaid Services (CMS) reimburses Chronic Care Management Services under CPT code 99490*, which includes a minimum of 20 minutes of non-face-to-face care management services per patient per month under the general supervision of a physician.


Quest Diagnostics offers Quest Chronic Care Management (CCM) Services, a CMS-compliant solution that helps clinicians extend care between office visits to patients with multiple chronic conditions.


Physicians oversee the creation of care plans and stay engaged as patients are managed by Quest nurse care coordinators. Every encounter is properly tracked in a monthly report to the practice. Learn more in the white paper.


In this emerging era for healthcare, in which patient contact and engagement are being further scrutinized, health coaching and its benefits to patients and practices are worth considering.


* The CPT codes provided are based on AMA guidelines and are for informational purposes only. CPT coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.



1. Dubé K, Willard-Grace R, O’Connell B, et al. Clinician perspectives on working with health coaches: a mixed methods approach. Fam Syst Health. 2015;33:213-221.

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