Health Coach Workflow Models in Clinical Practice: Part I
There is a lot of pressure for Functional Medicine practitioners to ‘do it all’. We are joined by two phenomenal health coaches in this two-part series that show you there is a better solution through two highly effective, albeit exact opposite, infrastructures. Learn about how these clinical practices found their health coaches to be so impactful, the coaches are now called the “secret sauce” to the practices’ success.
Therapeutic Parnterships Roadmap Course
The Therapeutic Partnerships Roadmap provides the framework for practice and patient success from getting the right patients through the door to keeping them engaged long enough to experience profound clinical outcomes.
“Working with you has been fantastic, and I appreciate all the hard work that you did to organize and revamp my practice. I’m no longer working on the weekends!” Dr. Barbara Johnson, MD
Guest Expert - Ashely Howell, NBC-HWC, FMCHC
Ashley Howell is a Board Certified, Functional Medicine Health Coach with over 15 years of experience in nutrition and wellness coaching and 8 years of experience working as the lead health coach at Modern Medicine in Dallas, TX.
Ashley’s health coaching journey began in 2000 while working as a CPhT in a compounding pharmacy in Austin, TX. She quickly realized she could change, not only her own health for the better but the health of others using lifestyle medicine and complementary nutritional therapies. After continuing her education through CE courses offered by the NIH and IFM, she eventually enrolled at the Institute for Integrative Nutrition to complete her certification as a holistic health coach through the American Association of Drugless Practitioners.
Ashley is also a proud member of the American College of Lifestyle Medicine. The ACLM is a medical professional society that provides quality support and continuing education to healthcare providers who are dedicated to using lifestyle medicine in clinical practice.
Kara Ware: (00:00)
This is Good Medicine On the Go.
Nathan Morris: (00:10)
So in last week’s episode, Coach Meg taught us that the biggest missing intervention in healthcare is a health coach, which I would really agree with, Kara. And maybe you’ve already tried to integrate a health coach, and I know some people have, and you really found yourself left with more questions than answers. I found that to be the case as I talked to providers, and like, “Why aren’t you using a health coach?” They’re just like, “Well, where does that really fit in?” Without a strong infrastructure, it isn’t always successful and can leave practices and the coaches frustrated.
Nathan Morris: (00:41)
So the question is how do we integrate a health coach into a functional practice? What does it look like and how can we make it a seamless addition to your care team? Some big questions that came up for me, especially at this time, is this virtual, or is this in-person? That’s one you need to look at, is this a salary or is it 1099? 1099 is basically a contracted position where you don’t have to do all the things that are associated with a salaried employee. Then should the patient see the coach before or after the provider? I kind of lend to both, because seeing the health coach before was one of those real paradigm-shifting things for us, right, Kara? Where we’re like, “That really is a good place for the health coach to fit in,” and it’s been magical for us.
Nathan Morris: (01:30)
So we’ll take a look at that too. In the next two episodes, you’ll hear two very different models for using a health coach, both of which have been very effective. So this is really exciting because we’re going to give you a practical aspect of how this can work and how you can implement it from two different perspectives. So I’m super excited about what we’re going to learn.
Kara Ware: (01:51)
And remember the theme running through season two is why and how to integrate a health coach and a functional medicine practice to make functional medicine more approachable, affordable, and sustainable. Remember those three words. So to improve patient retention and open functional medicine up to a broader audience.
Kara Ware: (02:24)
Hello and welcome. I am Kara Ware, a national board-certified health coach, and business advisor.
Nathan Morris: (02:33)
And I’m Nathan Morris, a medical doctor who is also certified in functional medicine.
Kara Ware: (02:37)
In today’s episode, this is the first of a two part series where we examine today a traditional workflow of a health coach. And if you are ready, if you’re listening and you’re convinced and you’re ready to integrate a health coach in clinical practice, this is one of the most effective ways to hire a health coach and immediately get started. So remember, in a later episode, we will be unpacking where to find a health coach and the interview and hiring and training and maximizing health coach in practice. But today we’re going to talk to a national board-certified health coach, Ashley Hal. In this episode, you will hear the unique integration workflow they have perfected after eight years of collaboratively working together. You’ll hear tips for communication channels inside a practice and care team collaboration, and also you’ll hear why is this infrastructure an easy way to integrate a health coach and hit the ground running as a team?
Kara Ware: (03:38)
So our guests today, Ashley Hal, she started over a decade ago working at a compounding pharmacy in Texas. This was a position that Ashley sought out more for income than really pursuing her true calling, but as does life happen, right time right place, and as Ashley began this job in this compounding pharmacy where they had a lot of nutraceuticals available, she entered into this entirely new world. This whole new world was revealed to Ashley about healing the root causes, and it’s no surprise since so many of us find functional medicine because of our personal journey.
Ashley Howell: (04:18)
For me personally, in the pharmacy, just on a personal level, I had such an aha moment. At that time, I was on five to six different medications and I was in my early 20s. I went into that environment thinking, “Well, I’m on all these meds, but that’s just my lot in life. I just have to be on a PPI forever. I’m just going to have to be on this anti-depressant forever. I’m just going to have to be on X, Y, and Z.” You can go on and on. I was on several. So I had just had no clue, no clue at that time that what I was putting in my mouth was affecting my health. I just had no idea. I think I have a lot of compassion. I think most of us as health coaches have a lot of compassion for the people we’re working with because we were there.
Kara Ware: (05:03)
While Ashley was working at that compound pharmacy, she heard about this health coaching position at the practice of Modern Medicine. Fast forward, Ashley has successfully been integrated as the health coach for the past eight years. She is truly a pioneer in our profession. So you will hear more about the provider, coach, integration workflow, Ashley’s role, and responsibilities as the lead health coach, how Ashley works collaboratively with the medical providers, and how she gets paid right after this.
Kara Ware: (05:44)
This podcast is sponsored by the Atrium Innovations family of professional brands, offering evidence-based supplements, advancing scientific research and providing clinical protocols and technology to empower practitioners globally. Atrium Innovations brands include Pure Encapsulations, the number one trusted and recommended brand by practitioners, Douglas Laboratories, Genestra Brands, and LivingMatrix, the fastest growing digital patient management system for functional medicine.
Kara Ware: (06:27)
So will you share with us about your workflow integration? What does that look like? Do you see the patient first? Does the provider see the patient first? Walk us through that series of encounters that your new patient has with both the medical providers and coach.
Ashley Howell: (06:45)
It really does start with the patient going through orientation. It’s important for us to make sure that we’re the right fit for the patient before they even come on board.
Kara Ware: (06:55)
Yeah, tell us just very briefly about how do you deliver that orientation?
Ashley Howell: (06:59)
Well, in the old days Dr. Rice and I both would give an in-person orientation. So we would have a list of people that wanted to establish care, and we had scheduled orientations after work hours and he would give the clinical part of it and I would give the nutrition health coaching part of it, and it was awesome. It really was great, but it started to become a real hindrance to the patient. We wanted people to get in faster. We didn’t want people to have to wait until our next orientation before they could establish care.
Kara Ware: (07:32)
Okay. So then what was your next iteration? Yeah, I love the learning curve.
Ashley Howell: (07:37)
I know, right? We all have it. Basically what we’ve moved to is just having them fill out a written orientation. So the patient now is going through and filling out a written orientation. So we’ve basically put everything that we used to speak on into a form that they’re basically checking off and signing, just stating that they understand clearly what kind of practice we are, what they can expect from us, and what we expect from them. That’s really where it starts. They can’t actually schedule an initial visit without having signed that.
Kara Ware: (08:11)
I love that. So everyone’s on the same philosophy and the agreements of each participant’s role is being established even before you see the point.
Ashley Howell: (08:20)
Exactly, and I think that’s really critical.
Kara Ware: (08:23)
That orientation is a crucial piece. I hope our listeners are hearing that as really the patient’s first point of contact. Then where does the patient go next? So they’ve decided, yeah, they’re ready to work with your practice. It’s a good fit. What happens next?
Ashley Howell: (08:38)
So then they come in and they will see either one of our doctors or they’ll see our nurse practitioner and they go through an initial, very comprehensive visit with them, with an intake that’s a little bit … it’s more clinical oriented. So they’ll do that at first and then after that, they’ll come in and see me for what Dr. Rice loves to call an audit. So a diet and lifestyle audit. So we just go through what their typical diet looks like and we’ll go through what life looks like day to day. We talk about what their stressors are in life, what do they do when they feel stressed, what are their typical stress reduction techniques that they use even unknowingly.
Kara Ware: (09:23)
Ashley Howell: (09:23)
Then exercise habits, water intake, all the things. We just kind of go through all of that. Then we leave it at that. So there’s no action plan or action steps that we go through at that point. It’s just sort of our baseline.
Kara Ware: (09:37)
So they see the medical provider, which is very overwhelming because you’re going over very complex, deep core clinical imbalances. So they see the provider for like an hour, right? Then I remember you had shared in a previous conversation that then typically they go for a lab draw in your clinics. Then does the provider walk the patient over to you for that audit? How does that transition happen in your practice?
Ashley Howell: (10:02)
That particular transition is just the medical assistant. After they draw the lab, the medical assistant is the one that brings the patient over. If for whatever reason, they don’t get a lab drawn at that point, then the provider will bring the patient over. But I would say typically it’s actually the MA or the nurse that will do that. Dr. Rice or our nurse practitioner, Michelle, will just prepare the patient for it. “Ashley’s going to see you next. She’s going to do this,” and it goes pretty much like that.
Kara Ware: (10:34)
What a beautiful, seamless experience. So I can only imagine being a patient in your practice. So I see the provider who I’m so ready to see. I really want to see this provider and understand what are my core clinical imbalances, what’s causing this. Please let me know. I don’t want to always have to live like this. Then they have a break. They kind of get up, they walk around, they have their lab drawn. I can imagine they get some water. The medical assistant is preparing them to see you, and then they bring them to you. Then here you’re not trying to change anything. You’re just getting a baseline. Like, “Hey, what are we working with here?” So I love how there’s no overwhelm the way you have this organized. Right?
Ashley Howell: (11:11)
Yeah. Another really big part of that first visit is building rapport. Building rapport, building some trust, doing a lot of reflective listening, and really making the patient feel comfortable. There are times where after the evaluation by the provider there may be some adjunctive lab work that the provider would like the patient to do before their next visit, and so that’s another thing that I might end up going over with them is that lab work, that additional lab work that the doctor or the nurse practitioner is wanting.
Ashley Howell: (11:42)
So we’ll go through that as well sometimes. Then one thing that I didn’t mention as far as that intake is concerned is the last thing I always ask patients is I always ask them “On a scale of one to 10, how ready, willing, and able do you feel like you are right now to make a change, to make diet and lifestyle change based on everything that we talked about today, based on what Dr. Rice or Michelle are going to find in your, in your lab work?” I always say 10 being, “Just tell me what to do. I’m going to do it,” one being, “I’m just not at a place where I can wrap my mind around making any change.” As you can imagine, most everybody is … if not a 10, very close to a 10. Once they’ve gone through that new patient orientation, once they’ve invested, even financially invested, in coming in and seeing us, they’re very, very ready to do what we’re recommending them to do.
Kara Ware: (12:35)
Yeah. Confidence is such an important piece of that equation, is that they feel like they can move forward. That self-efficacy piece, right, of the twin engines of change. The way you have this setup, I can hear that you’re not overwhelming them. You’re welcoming them. You’re embracing them. You’re creating that rapport and that trust. You’re figuring out, you’re gathering that information. “Where are we right now? And now we’re going to see you back and then we’ll make a clinical and lifestyle plan when you come back for your follow-up.”
Kara Ware: (13:02)
Okay. So I heard a one hour provider encounter. I heard a lab draw, maybe some other labs, and I heard an hour with you. Then those are all bundled together in your new patient program. Is that like one package? Are labs included?
Ashley Howell: (13:18)
The labs are not included. So the cost of the labs, that’s between the lab company and the patient. So that’s a little bit different. As far as the time, though, and the visit, it’s all bundled together. The timing’s a little bit different. So typically it’s more like 45 minutes with the provider and 30 minutes for me for that initial intake. Yeah. So it’s a little bit different, but I will say too that my understanding of where they are on that scale as far as their readiness to change is so helpful for me. It’s helpful for me to know where they’re starting mentally with all of this because they’re going to end up coming in and seeing me after the lab review. So just knowing where they are on that readiness scale is really helpful, I think too, just for me.
Kara Ware: (14:06)
Clearly, you’re knocking it out of the park, because if they’re all at a 10 … Coach Meg, Margaret Moore, we just spoke to in the last episode and she says on the confidence ruler, we really want someone to be a seven, maybe a six and a half. But that from six and a half, seven to 10 is really where change can happen. Now are follow-ups included in that initial bundle, or is this another bundle?
Ashley Howell: (14:27)
There’s another bundle. Those are longer visits. So as you can imagine-
Kara Ware: (14:31)
Yeah, well after you get into co-creating the plan.
Ashley Howell: (14:33)
Yeah, exactly. So that co-creation takes time so that typically is a 60-minute visit with the provider and then usually a 60-minute visit with me as well.
Kara Ware: (14:46)
Yeah. But they’re ready and they know you both and that rapport and that trust is established and now you are genuinely working as therapeutic partners. I can hear it. I mean, it’s clearly visible and I’m grateful that you’re sharing inside your practice and the success that you’ve learned over these last eight years.
Kara Ware: (15:08)
So now we kind of have an idea of the sequence and how we’re preparing the patient for this partnership and this process and everyone up for success. Now tell me about your communication systems between you and the provider. How does the provider … how do you collaborate? What do those communication channels look like? Are you charting notes and the provider’s reading your chart notes and you’re reading the provider’s chart notes? I just kind of want to understand those communication channels.
Ashley Howell: (15:32)
That’s exactly what happens. So I chart everything that I go through with the patients, and of course, the providers are as well. That’s really important, especially if for whatever reason I don’t see the patient right after their lab review. Sometimes that happens. If they’re doing adjunctive lab work and it takes longer to get that additional lab back in, they won’t see me until we have all the information. They may actually come back in and see the provider for the blood test results first. Our providers here do end up allowing me to go through the additional lab results with patients. So that could be stool testing, that could be adrenals, it could be neuro-transmitters, it could be micronutrients, or it could be a variety of different testing that we might do in addition to the blood work. So I’ll go through those results with the patient.
Ashley Howell: (16:22)
It just takes the burden off of the provider and allows them, of course, to move on and see new patients and do other things. So I’ve been well-trained to do that with patients, and so in those cases, I won’t see them right after seeing the provider for the lab review. That’s when it’s really, really important for me to be able to go back into their chart, see exactly what the provider went through with them, see what the big picture is for that patient as far as they’re concerned, the clinical goals basically so that we can make sure we go through that as well. But more often than not, Kara, we’re having a verbal conversation. There’s a lot of verbal that happens too. So, yeah.
Kara Ware: (17:04)
Just pausing here. It’s amazing that Ashley is interpreting lab tests. This is not something coaches are trained to do. Ashley has been in the field for many years and the providers at Modern Medicine have trained her to take this on after years of experience with their clinical care team. Now, back to the interview where we began to hear what Modern Medicine’s team communication looks like.
Kara Ware: (17:30)
Tell us a little bit about your team communication.
Ashley Howell: (17:33)
We actually bring our office manager into that as well, so we want to make sure she’s involved too and some of the more business-related topics. But, no, I love the meeting of the minds and that was something that Dr. Rice came up with and wanted to do. It just kind of keeps everybody on track. Even our nurse practitioner has her niche, too. We do aesthetics here at the practice, and that’s really something that she’s taken on and just does an amazing job with. Dr. Rice just to the updates. “What’s going on there? What’s going on with health coaching? Do we have anything that we need to modify? Do we need to adjust the flow or whatever the communication might be with the patient?”
Ashley Howell: (18:16)
We had an issue not too long ago where we were noticing that we had some patients that were kind of overwhelming both myself and our other health coach with a lot of email communication. It was getting to where we were spending a whole lot of time working with patients through email and that’s not compensated at all. So that was a real challenge and we were trying to sort of work through that.
Kara Ware: (18:39)
How did you solve that?
Ashley Howell: (18:40)
Well, honestly, I wish that our EMR had a better portal. That was the initial action plan for us was to get the portal up and running and try to communicate in that way. That didn’t work very well. So ultimately what we did was we just put a notice on our signature on the emails that depending on the content of the email, we may have to recommend that they come in and see us in person for a visit. Or depending on the length of time since we’ve seen the patient, we may need to have them go ahead and schedule an actual visit. So we just made that disclaimer and so far, it seems to have worked pretty well. I think she and I, our other health coach and I, have done a good job, too, just explaining that to patients when necessary.
Kara Ware: (19:27)
These are all back-office systems that crop up as you go along and practice development, that was like, “Oh, we have to develop a system here.”
Ashley Howell: (19:35)
Yeah, it’s true. It’s so true, and I think from my perspective, and I know from our other health coach’s perspective too, we don’t ever want the patient to feel like they’re alone. We don’t ever want the patient to feel like they’re not being supported in some way. So knowing how to very diplomatically and very positively explain that to the patient, I think is really important. But so far so good.
Kara Ware: (20:04)
So eight years ago the practice absorbed your cost because then they were in insurance and there were not CPT codes as there are today, which we will hear from Leigh-Anne Webster of the National Board [inaudible 00:20:17] of Health and Wellness Coaches, which you are a board-certified coach. It’s exciting that our profession is truly becoming validated in science and as a complement to medical providers in the healthcare space. So the practice believes so completely, your two providers, in this coaching position that they actually absorbed your cost in that insurance-based model. So are you still on salary today as they transitioned into the cash model?
Ashley Howell: (20:45)
Yes. Yes, I am. Yeah, it just sort of goes to show you though, too, in the very beginning, how critical they felt that this position was in their practice that they were willing to absorb that cost. But they were absorbing a lot of costs back then because the insurance model really does not work well for this model of care.
Kara Ware: (21:10)
As you heard today, and you’ll hear in the next episode, health coaches will have many talents and skills above and beyond health coaching that providers can utilize for the success of their practice. Today, we heard how Ashley has been well-trained for some lab interpretation responsibilities. In summary, Ashley’s providers refer to their health coaches as the secret sauce, the x-factor. They view the health coaches as equally valuable, equally necessary skillset as part of their collaborative care team.
Kara Ware: (21:44)
So Modern Medicine has since transitioned to cash and has kept Ashley as a salaried employee, and recently Ashley was responsible for interviewing and hiring and training a second health coach to join the Modern Medicine team and this health coach is a full-time position on an hourly rate.
Kara Ware: (22:03)
The next episode of this two-part series, you will hear an infrastructure where the coach is a 1099 independent contractor who invoices the practice. So salary, hourly or contracted position, lots of options when deciding how to pay a health coach.
Kara Ware: (22:24)
How would you summarize your health coaching, the lead health coach role, and responsibilities in your practice?
Ashley Howell: (22:29)
I would say my priority number one is something I say to patients all the time. It’s being the implementation department in the practice. So when we’ve got healthcare providers that are prescribing diet and lifestyle change to treat chronic disease, compliance isn’t just a nicety, it’s a necessity. So being the implementation department, sitting here with the patient, molding what the doctor’s recommending to that patient, not trying to fit a round peg into a square hole, so to speak. We really want to make sure that whatever they’re recommending is molded to the patient and the way that we do that is to co-create. It’s to help co-creating that action plan and it’s building those action steps.
Ashley Howell: (23:18)
Ultimately our goal is just to help the patient reach their goal. Their goals are our finish line. So the implementation department, I would say that’s priority number one, and then really supporting and caring for and training up any health coach that’s coming in after me. I think that’s really critical too. I think is the lead health coach is making sure that our other health coaches are comfortable in what we do and that they understand the flow and that mostly, more than anything else, that I can just be a support to them and a mentor too.
Ashley Howell: (23:53)
So that’s another big priority as well. Then I’m so passionate about speaking just like I’m doing today and reaching other healthcare providers and really advocating for health coaching in the world of medicine. It’s so, so, so needed. You and I know that really well and with the opportunities that I have had in speaking with other healthcare providers, you can always see that light click on for them too. I just love to be a part of that conversation and really help, again, just advocate for health coaching and explain it in a way that I think most healthcare providers will understand and receive.
Kara Ware: (24:39)
Such a great interview. Let summarize some of the key takeaways. Modern Medicine starts every new patient with an orientation, which onboards the patients to understand and assume their roles and responsibilities, as well as understand the roles and responsibilities of the care team. The orientation begins the relationship development of the provider-patient equal therapeutic partnership. This is the very essence that makes the functional medicine medical model unique and effective.
Kara Ware: (25:12)
Ashley’s coaching visits are bundled with medical providers’ appointments. The very first visit with a medical provider lasts 45 minutes followed by a 30-minute diet and lifestyle audit with Ashley, who is known as the implementation department in the practice. Ashley says ultimately her job is to help ensure the provider’s recommendations are an equal match to the patient’s readiness and perceived current ability, and therefore she’s supporting the patients to successfully implement the medical and lifestyle recommendations, and it’s really important to be very clear these recommendations are always coming from the medical provider.
Kara Ware: (25:55)
They’ve also bundled their follow-up provider and coaching encounters. The followup bundle consists of a 60-minute provider appointment, and then a 60-minute implementation coaching session with Ashley. Labs and supplements, remember, are not included in these bundles. And ongoing coaching, well, that depends on what the patient needs, and at that time if the patient could benefit from ongoing coaching, then it’s easy for the medical providers at Modern Medicine to refer patients back to Ashley since the patient has already built rapport and trust and have experienced her value as part of the clinical care team.
Kara Ware: (26:35)
Ashley is in-person rather than remote and is a salary position. This workflow infrastructure is a fantastic model to hire a health coach and get started. As you heard today, and you’ll hear in the next episode, health coaches will have many talents and skills above and beyond health coaching that providers can utilize for the success of their practice. Today, we heard how Ashley has been well-trained for some lab interpretation responsibilities.
Nathan Morris: (27:04)
So let’s remember this is a two-part series. Love this episode, really great, and in our next episode, we’ll share our health coaches’ workflow that Kara and I developed over the past six years. And just remember as you’re listening to this, it takes time to perfect workflow systems. So you may not get it all right at first, as you try to implement this, but it can and should happen within your practice, to great benefit as you’ve already heard earlier from Ashley.
Kara Ware: (27:30)
So thank you to our sponsors, Pure Encapsulations, Douglas Laboratories, Genestra Brands, and LivingMatrix, and to our writing team, Kelsey Stafstrom and Paul Larkin for making this podcast possible. Remember to rate and review and subscribe and tell a friend because we are closely re-imagining the functional medicine journey to make it more approachable, affordable, and sustainable. So follow us and for more resources, go to karawarecoaching.com\podcast. That’s K-A-R-A W-A-R-E coaching.com\podcast.
Nathan Morris: (28:08)
Can’t wait, Kara.
I am a paid advisor at Pure Encapsulations, I do not have any other conflicts of interest. All podcast productions represent the opinions of the co-hosts and do not represent the position or the opinion of the sponsors. Reference by the presenter to any specific product, process, or service by trade name, trademark, or manufacturer does not constitute or imply endorsement or recommendations by the Sponsor. The podcast is not a substitute for standard medical care. The podcast is intended for licensed health care practitioners. Practitioners are solely responsible for the care and treatment provided to their own patients.