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Promoting Healthy Behaviors through CHW Coaching


In a previous blog post, we introduced the mission of Activate Care and described some of the ways Activate Care supports Medicaid and Medicare beneficiaries through Community Health Worker-led interventions. We focus on helping individuals address their health-related social needs (HRSN) through social needs screening and connection to services (including housing, transportation, and food) and behavioral coaching

HEDIS (Healthcare Effectiveness Data and Information Set) measures performance in health care where improvements can make a meaningful difference in people’s lives, particularly those with chronic conditions. It’s widely recognized that health plans often struggle to meet HEDIS quality measures for chronic diseases such as diabetes and hypertension, leading to less than optimal care and outcomes for patients with these chronic conditions. Inconsistent medication adherence, challenges with weight management, limited access to nutritious foods, and insufficient physical activity can all hinder the effectiveness of treatment and potentially lead to less favorable patient outcomes. 

Effective management of chronic conditions is crucial for achieving good patient outcomes, controlling healthcare costs and utilization, and improving HEDIS quality performance. Health plans seek partners to improve HEDIS quality metrics by creating opportunities to broaden interventions and improve health outcomes, including CHW-led coaching on health behaviors to improve self-management of chronic conditions. 

Behavioral coaching aims to boost the client's healthy behaviors and, ultimately, foster confidence and self-efficacy—the belief in one’s ability to succeed. Key elements include: 


  • Client-Centered Approach: Client-centeredness starts with an understanding of the client's unique needs and motivations. Strategies should be tailored to address the individual client's circumstances, preferences, and abilities. 

  • Boosting Confidence and Self-Efficacy: Coaches provide positive reinforcement to help clients overcome obstacles and persist in their efforts. By focusing on successes, even small ones, positive reinforcement helps to motivate and encourage the client to continue their efforts.

  • Goal Setting: Together, the coach and the client establish specific, measurable, achievable, relevant, and time-bound (SMART) goals. By breaking down goals into manageable steps, clients are more likely to stay motivated and see progress. 

  • Using evidence-based strategies: Strategies may include: motivational interviewing, cognitive-behavioral techniques, goal-setting approaches, and behavior tracking. By using evidence-based strategies, coaches can ensure that their interventions have a higher likelihood of success. 

Informed by CDC guidelines and principles of Mental First Aid, Activate Care is currently exploring extending our coaching modules to include coaching on health behaviors. Areas for potential consideration include:


  • Medication Adherence: CHWs can help clients understand their medication regimens, address concerns or misconceptions, and develop strategies for incorporating medication-taking into their daily routines. 
  • Healthy Eating: CHWs can provide education on healthy food choices, meal planning, and mindful eating. They can offer nutrition education tailored to an individual's dietary preferences, cultural background, and health goals. 
  • Weight Control: CHWs can assist individuals in setting practical weight loss or weight management goals. They can help clients identify barriers to weight control, such as habits related to eating or activity levels, and collaborate on strategies to overcome these barriers. 
  • Physical Activity: CHWs can encourage individuals to incorporate regular physical activity into their lives according to their fitness levels and preferences. They can offer information on safe and enjoyable exercise routines, as well as resources for accessing physical activity programs or facilities in the community. 
  • Management of Chronic Diseases: CHWs can support individuals to understand their chronic condition, monitor their health indicators (e.g., blood pressure, blood sugar levels), and follow their prescribed treatment plans. CHWs can facilitate access to healthcare services, assist with appointment scheduling, and provide emotional support to individuals managing chronic diseases. 
  • Mental Health: CHWs can offer support, guidance, and resources to individuals experiencing stress, anxiety, depression, or other mental health challenges. They can provide empathetic listening, emotional support, and practical coping strategies to promote well-being. They also aim to reduce stigma and encourage help-seeking behaviors.


Research indicates that investing in Community Health Worker-led programs can result in significant savings in healthcare costs and improve HEDIS quality scores for chronic conditions. Health coaching can lead to improved outcomes, enhanced trust, lasting behavior change, and the opportunity to overcome health-related challenges. 


Learn more about our program and services here