Medical Home and the role of the RN Health Coach

   For their first meeting of 2013 at Prante's at noon on January 8th members listened to Kara Trom a Registered Nurse from Sanford Clinic Wahpeton explain the concept of the RN Health Coach.  It is a community based primary care concept that coordinates a patient's care by a RN Health Care Coach that has recently been adopted by Sanford through a grant from the State of Minnesota.  Initially Sanford has only one RN Health Coach, Ms. Trom, and is focusing on diabetes and hypertension as well as issues related to medication and transportation.  Ms. Darlene Holtz, RN Sanford Wahpeton's Director of Clinical Care and Ms. Trom's supervisor explained that eventually Sanford hopes to expand the program. Currently there is no cost to the patient.

   The basis of the concept is to get away from single incident medical care and focus on the whole patient.  In the old model a diabetic might have a sore throat, see his physician and receive treatment for that sore throat.  Current reimbursement practices does not allow the physician to do more.  With the RN Health Coach concept intervention begins even before the patient arrives when the record is checked; laboratory tests needed or due to manage, for example diabetes, are ordered and a review is conducted to see if specialists appointments are needed (for example if it has been over a year since the diabetic saw an optometrist for review of diabetic changes in the retina).  Family and friends are also a part of the team so support measures away from the clinic are reviewed.  During the time the patient is at the clinic about their sore throat the RN Health Coach goes over these other issues and makes sure that the continuing care for the whole patient is current.  Goal setting with the patient is also done; for example, the diabetic patient is not adequately testing their blood sugars so the patient is assisted in setting a goal of doing that.  Post visit the RN Health Coach follows up with the patient with respect to coordination of care with other care entities, soliciting patient concerns, goal monitoring and relationship building so that the patient, an the patients family and/or friends know they can always contact the RN Health Care Coach with concerns.