With a new year upon us, now is the time to reflect on current services being offered to patients and to create a plan of action to scale services for at-risk patients. Care Management services should be a major focus for Community Health Centers to define enrollment milestones, improve outcomes and ensure quality measurements are met. Don’t have the staff time for enrolling patients for Care Management services? Read on to learn what addition to the care team can cover these needs, and more.

The Centers for Medicare & Medicaid Services (CMS) recognizes specific services that can be delivered to Medicare patients under Care Management, including Chronic Care Management (CCM) and Behavioral Health Integration (BHI). CCM, in particular, is a Care Management service that CMS recognizes as a vital part of care that leads to overall improved levels of health for patients with two or more chronic diseases.¹

About 40% of American adults suffer from two or more chronic diseases. Chronic diseases can limit a patient from regular daily activities, and they cost the nation about $3.5 trillion per year in health care costs.²

There are proven ways to combat these chronic diseases, including consuming a healthy diet, getting adequate amounts of sleep, exercising regularly, getting screened regularly and more. Almost all of these methods follow a common trend, and that trend is helping patients take care of their own health and engage in preventive care. 

One addition to the care team that can support patient goals and engages with them to meet their CCM goals are health coaches. While the general healthy habits can be practiced independently, studies show that using a health coach can lead to better physiological, behavioral, psychological and social outcomes for patients through routine engagement and a developed relationship.³


There are many benefits of incorporating health coaches into clinical workflows, some include: 

  1.   Health coaches help patients discover their vision of optimal health and well-being as a whole.
  2.   They hold patients accountable in different ways than family or friends can.
  3.   Health coaches track a patient’s progress one step at a time while a doctor’s visit is usually periodic and brief.
  4.   They lead patients to self-efficacy and educate them on how to improve their behavior indefinitely.


Research has proven that using health coaches, particularly through telehealth, can significantly help patients in lower-socioeconomic communities with type two diabetes lower their HbA1c level, a measure that can be a sign of further complications with the disease. Besides their HbA1c levels, those patients using a health coach through telehealth also reported a significant change in waist circumference and body weight.⁴

Certintell’s telehealth services allow the health coach to remotely and conveniently monitor the various levels and habits of their patients in real-time using secure messaging, video calls, and Remote Patient Monitoring (RPM). Certintell can help patients receive the care they need through CCM while utilizing a remote health coach along the way. And now is a great time to start or scale Care Management!


Get Your Care Management on Track



¹ “Care Management.” CMS, 20 Nov. 2019, www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Care-Management.

² “About Chronic Diseases.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 23 Oct. 2019, www.cdc.gov/chronicdisease/about/index.htm.

³ Kivela, Kirsi, et al. “The Effects of Health Coaching on Adult Patients with Chronic Diseases: A Systematic Review.” Patient Education and Counseling, vol. 97, no. 2, 22 July 2014, pp. 147–157., https://static1.squarespace.com/static/57f289a2bebafb0ef756b9a7/t/582de08559cc686b2ebf72e1/1479401605746/HC-full journal article.pdf.

⁴ Wayne, Noah, et al. “Health Coaching Reduces HbA1c in Type 2 Diabetic Patients From a Lower-Socioeconomic Status Community: A Randomized Controlled Trial.” Journal of Medical Internet Research, vol. 17, no. 10, 5 Oct. 2015, doi:10.2196/jmir.4871.