Transforming Health Care Together

Chronic Disease Prevention Coaches Helping Adirondack Health Patients Make Significant Progress

Adirondack Health has long sought to curtail the incidence of chronic disease in its community. When DSRIP funding became available from the AHI Performing Provider System to support innovative health care projects, the health system applied for and was awarded funding to support the hiring of chronic disease wellness coaches. Since October 2018, coaches have been working in the hospital’s health centers, providing one-on-one patient consultations for diabetes, hypertension, elevated lipids, obesity, tobacco use, and stress.

According to Sylvia Getman, Adirondack Health’s President & CEO, patients have made significant progress with the help of the coaches. “Adirondack Health would have not been able to undertake this population health initiative without DSRIP funding. We hope to continue to offer these services to our community members and encourage healthy lifestyles which lead to better health outcomes.”

“The wellness coaches assess, assist, and monitor patients in making lifestyle changes to further reduce and reverse the risk of developing chronic disease,” explained Heidi Bailey, the organization’s Population Health Manager. “The coaches have helped individuals in so many ways. They’ve used motivational interviewing techniques to promote effective behavioral change, worked toward certification as tobacco treatment specialists, and helped guide people through the process of completing advanced directives and health care proxy forms.”

Since the program’s inception, the health centers have had 312 encounters with qualifying patients looking to lose weight, quit smoking, receive nutritional counseling, and more. Of that group, 30 percent had type 2 diabetes, 38 percent were overweight, 38 percent had pre-diabetes, 20 percent were smokers, and six percent had stress management issues.

Bailey shared some impressive statistics illustrating the success of the initiative:

  • Of 86 participants with pre-post weight recordings, 66 (76 percent) have recorded weight loss.
    • Of the 86 participants, 16 (19 percent) have lost more than five percent of their initial body weight.
  • Of 80 individuals with pre-post activity frequency measures, 32 (40 percent) increased from their baseline activity frequency and 47 (58 percent) maintained their activity frequency.
    • Only one out of the 80 individuals decreased in activity frequency during the measurement period.
  • Of 41 patients wishing to quit smoking, four (9.75 percent) have quit and maintained cessation.
  • Regarding changes in A1C, 26 participants had a pre-post A1C measurement.
    • Of the 26 participants, 18 (69 percent) have experienced a decrease in their A1C measurements.

The program has substantial aspirations moving forward. “We’re excited to have received accreditation from the Centers for Disease Control and Prevention to lead the next National Diabetes Prevention Program in Spring 2020,” shared Bailey. “We’re also working toward implementing the national Baby & Me – Tobacco Free program with the support of the North Country Healthy Heart Network to address the New York State Prevention Agenda priority areas of promoting healthy women, infants, and children, and preventing chronic disease. We have so much going on and it’s truly gratifying to see the amazing results of our efforts to help those with chronic disease lead healthy and productive lives.”

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