Health Coach Program to Improve Chronic Disease Outcomes Following an Emergency Department Visit

Patients will be recruited by health coaches from the Highland Hospital Emergency Department.
Eligible patients who agree to participate will be randomized to the control and experimental
groups in a 2:1 ratio respectively because experimental group size is limited by health coach
availability and greater loss-to-follow up is expected among the control group. Repeated
measures analysis will be used to compare each outcome over the study period. In addition,
subgroup analyses will be performed in order to stratify by baseline survey measures or
amount of ED visits in the pre-observation period.

Inclusion Criteria:

- Willing to work with a health coach

- Plans to reside in Alameda County for the next year

- Has a reliable phone number

- Speaks English or Spanish

- 18 years of age or older

- Meets at least one of the following three criteria: (1) Low medication adherence
defined as a continuous medication gap of at least 1 month in the past year OR a new
diagnosis of diabetes and/or hypertension; (2) No patient-identified primary care
provider (PCP) or no visit to PCP in 1 year; (3) One or more visits to the ED in the
last 6 months.

Exclusion Criteria:

- Life-expectancy less than 1 year

- Poorly controlled psychiatric illness

- Homeless

- Active and frequent use of illicit substances

- Currently incarcerated

- Already enrolled in a program for patients with high rates of hospitalization and/or
emergency department visits

- Unable to consent due to an unstable condition or serious emotional or neurologic
condition

- Admitted or anticipated to be admitted to the hospital from the ED