Studies have shown that if a primary care physician with a normal caseload were to deliver every aspect of recommended care to all his or her patients - including episodic and preventive care as well as all of the required paperwork - the doctor would need to work more than 24 hours per day.

Clearly, something has to give. Mercy Clinics of Des Moines, Iowa, has found a way to deliver high-quality care without defying the limits of physicians' stamina. It uses registered nurses as health coaches and tasks them with monitoring and managing the health of patients with chronic disease.

"A lot of what we're doing with the health coaches is off-loading work that physicians were doing - nursing and clerical work, for instance - so they can do physician work," explained Dr. David E. Swieskowski, vice president for quality at Mercy Clinics.

During an Innovation Forum session at the Catholic Health Assembly in June, Swieskowski and his colleague Kelly Taylor will describe how the coaching system is improving health outcomes and enhancing care quality - all while boosting the clinics' revenues. "Improving Outcomes with Health Coaches in Primary Care Offices," is one of 32 Innovation Forum sessions at the assembly, which this year takes place in San Diego.

Mercy Clinics is owned by Mercy Medical Center of Des Moines, which is part of Denver-based Catholic Health Initiatives.

Mercy Clinics started its health coach program in 2004 to patch a structural flaw inherent in U.S. health care delivery: physicians are called to manage patients' chronic conditions in a system designed for acute, episodic care. The concept of preventive care - so key to treating chronic illness - does not readily fit into the acute care model.

Enter the health coaches who focus on "high use" patients both as individuals and as data sets, looking for opportunities to help patients better their health and avoid complications and hospitalizations.

Managing disease
The coaches meet patients face-to-face or by phone. They talk through the patients' health goals, identify challenges and devise coping strategies. They follow-up to make sure solutions are working. The coaches can provide proactive, timely outreach. For instance, coaches may call patients to report and discuss lab results.

"Just sitting down with someone and finding out how they fit diabetes into their life opens the door to helping me to help them," said Monica Vail, one of 14 full-time health coaches employed by 12 Mercy clinics. "Finding out what they eat, where they work, what is important to them allows me to help them take control of their disease."

One woman Vail helped was a diabetic whose family was "nearly at their wits end." The patient's blood sugars "were all over the place, she wasn't answering her phone, didn't want to leave the house." The family was considering placing the woman in a nursing home. As part of a health assessment, Vail and a team of caregivers determined that the woman had undiagnosed depression. They were able to treat the depression and help her gain better control of her diabetes.

"The family was so relieved that their mom was OK and not headed for the nursing home," said Vail. "The daughter-in-law was in tears because she was so thankful that we had gone the extra mile and had taken the time to talk about depression."

In addition to their expertise in disease management, the coaches help with time management. Prior to a patient's office visit, a coach can order tests to inform the physician's assessment and secure referrals required by insurers.

Disease registry
The coaches contribute to disease registries that are used to track the health status of patient populations. In this context, a population is defined as a group with a common illness. Using this registry for a group of diabetic patients, for instance, physicians and coaches can look at indicators like blood sugar levels to determine whether new approaches are needed to achieve better control. They identify opportunities for quality improvements and coordinate with their peers to implement those improvements in physicians' offices.

Swieskowski said the approach is producing results. "What we find is that across the population a much higher percentage of them have their blood pressure controlled, a much higher percentage have their blood sugar controlled. Because of this, there will be fewer heart attacks, fewer strokes and fewer complications from diabetes."

Mercy Clinics' disease registry includes 8,600 patients with diabetes and 10,500 patients with hypertension.

Financial benefit
When Mercy Clinics first hired the coaches, some physicians were reluctant to share their duties with the new arrivals. The program gained momentum as physicians started to notice that colleagues who worked with the health coaches were achieving better results with less effort.

Mercy Clinics found that for every dollar that the clinics spend on the salaries of health coaches, the program brings in at least $4 in revenue. Much of the increased revenue is due to the caregivers delivering higher levels of billable service, ordering more lab work and increasing the number of patient visits. The heightened level of care is not superfluous, Mercy Clinics administrators said, it is preventive. In fact, the clinics' largest insurer recognized the value of the care in reducing the incidence of complications and hospitalizations, and it pays for health coach services.

"Quality improvement is not an expense - it is a revenue- and profit-generating activity for outpatient clinics," Swieskowski said.