Sara, 89, was recently discharged from hospital and subsequently a rehabilitation facility following a fall in her apartment which had resulted in facial fractures and broken ribs. Lucy, Sara’s daughter, was present during the visit with coach Traci. Although Sara would like to remain in her apartment, she now relies on a walker to get around and there is no elevator. Lucy explained that she is researching assisted living facilities and Traci was able to provide a contact at the Del Rey Square Senior Housing, which is targeted at very low income seniors. Traci also worked with Sara’s PCP to set up occupational therapy services. “Sara is very alert, and determined to retain her independence as long as possible. Finances are stretched, so I provided Sara and Lucy with information about Wise & Healthy Aging, which can provide them with support for Medi-Cal/IHSS eligibility assistance, and a low cost caregiving resource called Carelinx to help Sara with laundry and housework.”
Partners in Care Foundation uses “patient activation” models of health coaching to provide tailored support dependent on a patient’s knowledge, skills, ability, and willingness to manage his or her own health and care. Some patients are self-starters and all they need is connection to resources, while others need information, motivation and follow-up to close the gap. Here is the first of a series of stories about patients who have received health coaching over recent months. All names have been changed to protect patient confidentiality.