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By ontrak
October 4, 2023

The missing link: How holistic care coaches help members navigate a fragmented healthcare delivery system

By Judith A. Feld, MD, MPH, MMM, DLFAPA. Chief Medical Officer, Ontrak Health.

A recent Gallup poll found that levels of lifetime and current depression have reached an all-time high for Americans in 2023. So, it’s no surprise that health plans are working to address these challenges and increase access to effective mental and behavioral healthcare.

However, facing a fragmented health delivery system, the need for innovation in behavioral healthcare has never been greater. There’s a limited supply of providers. Strained facilities. And escalating costs.

Holistic care coaching helps members navigate a fragmented healthcare delivery system by taking a broader focus on a range of physical, social, and mental health issues. So, care coaching is not limited to focusing solely on conditions like anxiety and depression; and it’s also not solely focused on physical conditions like hypertension or diabetes.

In this way, holistic care coaching can help complement services from Managed Behavioral Health Organizations (MBHOs) as well as case managers. They can help fill essential care gaps and mitigate the fragmentation in the healthcare delivery system.

Behavioral health intersects with physical conditions in crucial ways.

Chronic medical conditions increase the risk of developing or worsening a comorbid mental health condition and vice versa. For instance, people with depression have been shown to have an increased risk of cardiovascular disease, diabetes, stroke, pain, and Alzheimer’s disease.

Holistic care coaching recognizes this and can effectively bridge the gap between the two. An integrated approach in caring for individuals with these comorbidities improves clinical outcomes and care affordability.

Holistic care coaching supports a true integrative approach by working with members to:

• Tie together optimized care for behavioral health conditions.
• Create meaningful and actionable goals.
• Improve self-efficacy.
• Empower self-management with chronic physical health conditions.

Behavioral health intersects with social conditions in crucial ways.

Because holistic care coaching looks beyond discrete conditions, it’s able to fundamentally address the entire spectrum of care barriers. From food, transportation, and housing insecurity to internalized stigma and broader community concerns.

Holistic care coaches are uniquely positioned to effectively address cultural norms and societal expectations that can often interfere with seeking help for mental health issues. Care coaching professionals are culturally sensitive and work to destigmatize behavioral health concerns. They provide support not just for the health condition, but also for the social and cultural aspects surrounding it.

By addressing these issues early, individuals are far more likely to stay in care while developing skills to navigate internalized stigma and other external barriers.

Care coaches can step in to help members avoid unnecessary treatment.

Many people may not immediately need a therapist or medication but could benefit from guidance and support. This is where the focus on both physical and mental health conditions can be a game changer for members as well as health plans.

For instance, a primary care visit assessment may reveal concerns around anxiety symptoms. Instead of immediately referring the member to a specialist, a primary care provider (PCP) may be able to support that member with the help and expertise of a care coach.

In this context, a care coach can more closely monitor a member’s progress with their care plan and, if needed, coordinate referral to an appropriate health care provider. This approach helps health plans reduce unnecessary utilization, helps members realize better health, and aligns with the member’s choice in healthcare.

Care coaches are there for members between provider visits.

The gaps in care are not just limited to care delivery, but also extend to the periods between provider visits. Many individuals may see their mental health professionals sporadically, and may greatly benefit from intervisit support.

Holistic care coaches help members understand and adhere to their treatment plans as needed. Toward this end, care coaches may:

• Support medication adherence.
• Provide educational, community and health plan program resources.
• Assess member progress on their health care journey.

This ongoing support is crucial in maintaining member progress, while actively contributing to the multidisciplinary care team.

Navigating a fragmented system

With our fragmented health delivery system, and its focus on specialist care for most behavioral health concerns, it’s rare for members to experience whole-person care. PCPs work hard to support more comprehensive care approaches, but with resource and time constraints, it’s extremely difficult.

That’s why care coaches bring tremendous value. By addressing the vulnerabilities in the healthcare journey, and by focusing on the whole person, care coaches can help address mental, physical, and social needs. They provide continuous support. And make it easier to navigate our complex healthcare system.

Above all, care coaching is about overcoming constraints. Expanding opportunities. And empowering members to achieve optimal wellbeing.