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Service Delivery Innovation Profile

Health Coach Program in a Medical Group Improves Self-Care and Decreases Readmissions for High-Risk, Chronically Ill Patients

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Dartmouth-Hitchcock Clinic assigned health coaches to high-risk chronic disease patients to provide instruction regarding health care needs. These coaches, who were integrated into Dartmouth-Hitchcock primary care practices, provided evidence-based information to patients by telephone, during office visits, and in group class settings, with the goal of improving patient self-management skills, better preparing patients for their physician office visits, encouraging physician–patient communication, and engaging patients in their care plans. An evaluation found that the program attracted a high percentage of eligible patients and reduced hospital readmission rates and costs for patients age 65 years and older. Information provided in 2013 indicates that the clinic continues to offer health coaching as part of a comprehensive care coordination program; the clinic now uses a different process for identifying eligible patients and no longer partners with a disease management company for program implementation.

Evidence Rating (What is this?)

Moderate: The evidence consists primarily of pre- and post-implementation comparisons of key performance metrics, including enrollment and readmission rates; comparisons show a clear, direct link between the program and improvements.
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Developing Organizations

Dartmouth-Hitchcock Clinic; Health Dialog
Dartmouth-Hitchcock Clinic is in New Bedford, NH. Health Dialog is in Boston, MA.end do

Problem Addressed

Disease management vendors across the country contract with health plans to offer telephone coaching to patients with a variety of chronic diseases, with the goal of preventing secondary complications of chronic illnesses and, therefore, reducing health care utilization. Although generally considered to be effective, externally run disease management programs exhibit shortcomings that limit their impact on patient health:
  • Limited patient uptake: The average enrollment rate for disease management programs that contact patients on behalf of health plans is only 7 to 13 percent, meaning that many high-risk patients are not being served.1 This may be because health plans often use out-of-date claims data to identify eligible individuals. One study found wide variability in health plans’ ability to identify populations eligible for disease management programs due to data quality issues.2
  • Limited influence on physicians: A study found little evidence that disease management nurses are able to influence physician decisions through their recommendations about patient care needs.2
  • Inability to coordinate services: Disease management nurses employed by vendors typically do not have access to practice electronic health records or scheduling systems and therefore often cannot make referrals for needed services.

What They Did

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Description of the Innovative Activity

Nurses trained as health coaches were embedded into physician practices and periodically contacted patients to offer personalized information and support regarding the patients' chronic illnesses. Elements of the health coaching program included the following:
  • Eligible patients: Individuals targeted for the intervention included patients with chronic diseases, including diabetes, congestive heart failure, hypertension, and coronary artery disease. Each eligible patient was offered a health coach.
  • Patient call lists: A file of patient information drawn from an electronic medical record (EMR) was regularly sent by Dartmouth-Hitchcock to Health Dialog, a disease management company that used the file to create lists of patients for the health coaches to contact.
  • Health coach duties: Each health coach received a patient list, referenced the EMR to access additional clinical information on each patient, and then called each patient. Specific duties included the following:
    • Initial introduction: During the initial call to patients, coaches introduced themselves as nurses in the patient’s primary care practice and explained how the program works.
    • Ongoing services: Services provided by health coaches were highly dependent on individual patient circumstances but typically included motivational counseling and education specific to the patient's disease and health status. The health coach decided which services were needed, although the physician may have also suggested certain services or conversations. (Because health coaches were located within the practice, they built collaborative relationships with the physicians and nurses.) Specific duties included the following:
      • Providing evidence-based health care information to patients by telephone, during office visits, by distributing educational materials, and in group class settings.
      • Making followup phone calls within 2 days of hospital discharge to ensure that patients understood their medications and that a followup visit with the physician had been scheduled.
      • Offering care coordination when needed (e.g., advocating for visiting nurse services or social services).
      • Accepting calls from patients with questions or concerns; the coach would either provide the information requested or refer the patient to the physician.
      • Making as-needed face-to-face visits. Although the majority of patient outreach was by telephone, health coaches may have some face-to-face visits with patients; for example, physicians may have asked coaches to meet with patients who are having particular difficulty in complying with their care plan.
  • Use of EMR and disease registries: Health coaches had complete access to the EMR system. By accessing the patient’s medical record, the health coach had real-time, indepth knowledge about the patient’s health status and could tailor the discussion to the patient’s needs. Health coaches also used Dartmouth-Hitchcock’s disease-specific patient registries to help prioritize patient calls and to address particular gaps in care during the patient interaction. In addition, a function in the EMR allowed the health coach to notify the primary care physician if a particular diagnostic test was needed, facilitating the scheduling of needed care.

Context of the Innovation

The Dartmouth-Hitchcock Medical Center is a not-for-profit multispecialty group practice with approximately 400 physicians serving about 1 million patients annually at 48 ambulatory care sites located across New Hampshire. The clinic was 1 of 10 sites in the United States selected by Centers for Medicare & Medicaid Services to take part in the Physician Group Practice Demonstration Project. The goal of this 3-year project (which began in 2005) was to improve quality while reducing costs by preventing avoidable illnesses and hospitalizations through strategies such as improving access to care, providing thorough preventive care, offering prompt followup care, and improving patient education and self-management. Project participation involved collecting and measuring 32 quality measures based on evidence-based best practices for diabetes, heart failure, coronary artery disease, hypertension, and prevention. A participating group could earn a bonus of up to 80 percent of any Medicare cost savings that it generated in excess of 2 percent of its target expenditures (the group was not penalized if it did not meet its target). Dartmouth-Hitchcock developed the health coach program in collaboration with Health Dialog to meet the challenges set forth by the Demonstration project. Although the Demonstration project ended, Dartmouth-Hitchcock continues to use health coaching as part of their comprehensive care coordination program, with modifications to program implementation.

Did It Work?

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The health coaching program attracted many more patients than the typical, outsourced disease management program and also reduced readmission rates and generated significant overall cost savings.
  • High patient enrollment: Roughly 77 percent of eligible Dartmouth-Hitchcock patients agreed to participate in the program, much higher than the typical 7- to 13-percent enrollment rate achieved by other Health Dialog–led programs. Approximately 3,600 patients have been coached to date.
  • Decline in readmission rates: The program prompted a statistically significant decrease in the readmission rate of the targeted patient group; the average readmission rate for patients aged 65 years and older dropped from 15.6 to 13.7 percent, a reduction that has been sustained for more than 1 year.
  • High quality and lower costs: Dartmouth-Hitchcock met all of the quality measures set forth by the Centers for Medicare & Medicaid Services Physician Group Practice Demonstration Project and saved Centers for Medicare & Medicaid Services $2.7 million. However, this level of savings did not meet the threshold for the clinic to receive a financial award in the first year. In year 1, Dartmouth-Hitchcock met all of its quality targets except one. (See Context of the Innovation for more information on the Physician Group Practice Demonstration Project.)

Evidence Rating (What is this?)

Moderate: The evidence consists primarily of pre- and post-implementation comparisons of key performance metrics, including enrollment and readmission rates; comparisons show a clear, direct link between the program and improvements.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Development of initial list of eligible patients: With assistance from the Dartmouth-Hitchcock information technology department, the clinic identified Medicare patients who had one or more of the conditions targeted by the Physician Group Practice Demonstration Project.
  • Identification of those patients at highest risk: Clinic physicians developed an algorithm to determine which patients were at greatest risk for hospitalization or complications. These patients became a priority for the intervention, with lower-risk patients to be enrolled if health coach capacity were available.
  • Development of patient call list: Health Dialog developed patient call lists with basic clinical information that were distributed to the health coaches.
  • Development of registries: The Dartmouth-Hitchcock information technology department created disease-specific registries that listed patients with each of the target chronic illnesses and identified gaps in care based on evidence-based recommendations. Registries only reflected care provided at Dartmouth-Hitchcock Clinic.
  • Health coach training: Health Dialog provided 2-week training for coaches, who were nurses. Training focused on Health Dialog’s disease management process, up-to-date chronic condition guidelines, assessment of patient readiness for change, proactive problem-solving, and motivational interviewing.

Resources Used and Skills Needed

  • Staffing: Dartmouth-Hitchcock employed six health coaches, each of whom had a significant amount of clinical experience. Each coach served an undetermined number of patients. (Because the frequency of health coach conversations with each patient varied significantly depending on the needs of individual patients, Dartmouth-Hitchcock cannot estimate the number of patients per coach). The program also required information technology staff to support the development of patient lists and disease registries.
  • Costs: The costs of the program included the health coach salaries and benefits, as health coach services were not funded by health plans. Although Centers for Medicare & Medicaid Services did not provide money to fund the infrastructure needed to build the program, Dartmouth-Hitchcock was potentially eligible to receive some gainsharing funds from Centers for Medicare & Medicaid Services as a part of the Physician Group Practice Demonstration Project; the clinic had an agreement with Health Dialog to share any financial gains awarded. In the first year of the program, Dartmouth-Hitchcock employed six health coaches (5.75 full-time equivalents) who coached 1,723 patients at a cost of $381,000.
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Funding Sources

Dartmouth-Hitchcock Clinic; Health Dialog
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Adoption Considerations

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Getting Started with This Innovation

  • Ensure that health coaches receive proper training regarding motivational interviewing and assessment of patient readiness for behavior change.
  • Employ a dedicated full-time coaching staff. If existing practice nurses are given coaching responsibilities to fold into their regular duties, health coaching will likely receive low priority and may not occur.

Sustaining This Innovation

  • Encourage health plans to consider providing reimbursement for coaching services; sharing data on the program's effectiveness in reducing costs can help in making the case for reimbursement.

More Information

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Contact the Innovator

Sheila A. Johnson, RN MBA
Director, Clinical Performance Management
One Bedford Farms Drive
Bedford, NH 03110
Phone: (603) 629-1168

Innovator Disclosures

Ms. Johnson has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Trisolini M, Pope G, Kautter J, et al. Medicare physician group practices: innovations in quality and efficiency. New York: The Commonwealth Fund and RTI International. December 2006; p. 12-14. Available at:
(If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software External Web Site Policy.).


1 Data from Health Dialog, Boston, MA as cited by Joan Tulk, Dartmouth-Hitchcock Clinic.
2 Pacific Business Group on Health. Disease management effectiveness project: a final report from the Pacific Business Group on Health. San Francisco: Pacific Business Group on Health, 2002.
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Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 13, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: August 05, 2010.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.