Care Coaches & Care Coordinators: Creating a Comprehensive Health Care Experience

Our goal is to make health care less stressful and more rewarding for our patients. We want you to feel well cared for, both in and out of the clinic. This is especially true if you have issues that make it harder for you to manage your health like: 

• Having several conditions at once, like diabetes, high blood pressure, or heart failure 
• Not having a car or other way to get to appointments 
• Trouble paying for medication  
• Not understanding your insurance benefits 
• Being unsure where to go if you do not feel well 

If you deal with any of these, our care coaches and care coordinators are here to help. They provide support and resources to solve these and other problems. They are a huge part of what makes Innovista different and unique.  

Care Coaches: Teachers & Mentors 

Your Innovista primary care provider (PCP) will always be the leader in your care. But if you have certain diseases, your PCP may want you to partner with a care coach. 

Care coaches are teachers, guides, and mentors. They also serve as a “bridge” between you and your PCP. They will share updates between you and your PCP so everyone stays informed. 

What can you expect when working with a care coach? 

After your PCP refers you, the coach will contact you. In Houston, care coaches are available for in-person visits. In Dallas, they can offer virtual consultations. 

At your first meeting, your care coach will: 

• Take/confirm your weight, blood pressure, and other measurements. 
• Ask about your diet and lifestyle. 
• Make a list of your medications. 
• Work with you to set health goals. 

Common goals include: 

• Improving bloodwork (like cholesterol or A1c) 
• Losing weight 
• Lowering blood pressure 
• Eating a healthier diet 

Your care coach will create a program unique to you, based on your goals.  

You will start with simple goals like walking more or giving up soda. After about three weeks, you and your coach will talk again. You will update your coach on your progress and discuss concerns. You may set new goals, too. This usually becomes your program for the next three months. You will continue to check in every four weeks to talk about wins and hurdles. 

At that point, you and your care coach may decide to set even bigger goals. Say you have been exercising for 30 minutes three days a week. You may be ready to move up to 45 minutes five days a week.  

These programs are designed to last six months. But care coaches genuinely care about your long-term success. They can continue to help even after the formal program ends.  

Care Coordinators: In-Depth Health Management 

If you have several medical issues, you know that life can get overwhelming trying to manage them. Innovista care coordinators can help manage your health care in many ways, making things a little easier for you. 

Care coordinators can make appointments and organize treatment plans. If you have five or more conditions, they arrange extra time with your PCP. They also can help you refill prescriptions, get referrals, and schedule visits with specialists. This direct request can help get you in with specialists faster than if you were to call yourself. 

If you have personal needs that affect your health or health care, care coordinators can find you help. Through partnerships with community organizations, they can set up rides to doctor appointments, find housing, assist with critical finance issues, and more.  

Transitional Care 

When you leave the hospital after a stay, you should always see your PCP. During this visit, your PCP can check how you are doing, update your medical chart, and order any follow-up tests. This process is called transitional care. The goal of transitional care is to make sure you get follow-up care so you do not end up back in the hospital unless necessary. 

Innovista care coordinators manage transitional care for patients. If you are ever discharged from the hospital, you will get a call from a care coordinator within two weeks. Your insurer, Blue Cross and Blue Shield of Texas, sends this information to Innovista. The care coordinator will plan all your follow-up visits and make sure you have what you need to prevent complications and recover at home.  

Care coordinators can also teach you where to go if you need medical care. Hospital visits are expensive. Unless you have a true emergency, they are not the best choice. For non-emergency care, your PCP should be your first choice. If Innovista is closed, an urgent care clinic or telehealth are good, less costly options.  

Helping patients make smarter decisions about their health care is always a top priority. When teamed up with a care coordinator, you have a direct line to someone who has your best interests at heart.  

Supporting You & Your Health Journey 

As a patient at Innovista Medical Center, working with a care coach or care coordinator comes at no additional cost to you. Usually, your PCP will refer you to one or both if you have at least one chronic health condition. To learn more or to request to meet with a care coach or care coordinator, talk to your Innovista PCP.