Health Coach Project

In the rural, older population of Oconee County, much of this emergent and hospital care is related to congestive heart failure, diabetes, and cardiovascular disease. Frequently, such care could have been avoided if the disease had been more effectively managed through better adherence to the home health care plan and prompt recognition of "red flag" signs and symptoms. Adherence can be improved by building patients' self-management skills and helping them navigate the complex network of health and social services. This project's model is designed to improve chronic disease management among rural, HHS patients through trained community volunteers called "Health Coaches." These coaches will help patients transition from home health services to self-care and family care by offering home-based education, monitoring, support, and referrals, thus reducing the risk for emergent and hospital care.

The project will implement best practices such as those tested in the South Carolina Rural Geriatric Initiative Project (SC GRIP). Health Coaches will be trained using the SC GRIP curriculum for geriatric technicians and will be trained to use the State's medical management materials, and its information and referral database. The also will be trained to implement Clemson University Extension nutrition and physical activity curricula. The project will build on these successful programs, integrate them with home health services, and organize strategies with the Chronic Care Model framework to coordinate care as the patient transitions along the continuum from acute care to self-care.