The best way to improve the health of high-risk patients might require case management that is sensitive to the population’s particular cultural, religious, and socioeconomic needs.

Chinle Comprehensive Health Care Facility in Chinle, AZ, created a program that employs culturally sensitive care management staff. Health coaches meet with patients to help them make their first doctor appointments and to navigate them through the healthcare system, says Ruth Finley, RN, BSN, outpatient department nurse improvement specialist at Chinle Comprehensive Health Care.

As part of the Navajo Baa Hózhó program, health coaches visit patients at home, as needed. They also might speak fluent Navajo, says Krista Haven, MSN, RN, CDE, diabetes nurse improvement specialist at Chinle Service Unit Diabetes Program and diabetes case manager at Navajo Baa Hózhó Program.

Finley and Haven explain how the program works:

• Enroll patients. Providers refer patients to the Navajo Baa Hózhó program. The healthcare facility uses a screening tool. “Care managers get information from the electronic health record [EHR], and they also interview the patient and family,” Finley says.

The risk screening tool is from the Northern Arizona Healthcare system, she notes. “The health system gave us this tool because we reached out to them, asking what we could do to help with transitions from hospital to home and then to the primary care clinic,” she explains. “They had this screening tool, which is based on the BOOST tool, and we adopted it for our population.”

Project Better Outcomes by Optimizing Safe Transitions (BOOST) uses the 8 Ps:

- Problems with medications;

- Psychological;

- Principal diagnosis;

- Physical limitations;

- Poor health literacy;

- Patient support;

- Prior hospitalization;

- Palliative care.

(For more information on Project BOOST, visit:

• Assess patient. Case managers meet with the patient and perform the first assessment, Finley says.

Case managers also use the Patient Activation Measure (PAM) and the EuroQol tool to assess functional status and to see how patients feel about their own health.

The EuroQol Group, in 1987, developed a standardized non-disease-specific instrument that is used to measure health-related quality of life. (Read more at:

PAM was first described in a study published in 2004. PAM is used to measure how actively patients are participating and engaged in their own healthcare. (More information is available at:

PAM was developed in four stages:

- Stage 1: Conceptually defining activation, using a literature review and consultation with experts and focus groups;

- Stage 2: Generating, refining, and testing a large item pool, building on the domains identified in stage 1;

- Stage 3: Extending the measure’s range as needed and testing whether the measure could be used with respondents without chronic illness;

- Stage 4: Using a national probability sample to assess the performance of the measure across different subsamples in the population.

“These tools help with determining patients’ functional status and determining how people feel about their health,” Finley says.

Patients review PAM statements and check the boxes of how strongly they agree or disagree with the statement. Sample PAM statements include:

- I am the person responsible for taking care of my health;

- I can tell my doctor about my worries, even when he or she does not ask;

- I understand my health problems and what causes them;

- I can figure out ways to fix new problems with my health.

PAM is a 100-point scale, which makes it easy to compare a patient’s status from week to week. “We look back and say, ‘You were a 70 last week; why do you feel your health has gone down?’” Finley says. “With PAM, patients sit and complete it themselves. It’s more of self-assessment.”

• Set SMART goals. “We have patients set a SMART goal,” Haven says.

SMART stands for Specific, Measurable, Achievable, Relevant, and Timebound. (Information on SMART is available at:

This approach works better than the traditional strategy of giving patients orders and expecting them to follow these without any consideration for the patient’s ability to understand, cultural issues, and motivational level.

“SMART goals are more collaborative than dictating orders to a patient,” Haven says. “This is how we get a patient on board and write a care plan that is based on the patient’s needs and wants.”

For instance, if a patient wants to make a doctor’s appointment, then case managers ask the patient to write down this goal. If the patient has heart failure concerns, he or she is asked to check weight at the same time each day, she explains.

“Then, we ask them, ‘Do you have a scale?’ And if they don’t have one, we ask them and a family member, ‘Do you have a way to get a scale?’ If there is no way for them to purchase a scale, we help them get one,” Haven says.

Health coaches help patients make their appointments and serve as assistants to case managers, Finley says.

Based on patients’ PAM and EuroQol scores, the team helps them set SMART goals. These are target behaviors and changes set at each visit.

“They say, ‘I want to try to walk more,’” Finley says. “We set a goal for the next two weeks, saying, ‘I’ll walk two minutes a day.’” The goals are written down, and the health coach calls patients to check on their progress.

• Embrace cultural awareness. The Navajo Baa Hózhó program strives for balance in patients’ medical care and lives.

“Everything about the culture is balance, and there’s a kinship way of life,” Haven says. “If you have something wrong physically, it might be related to your eating too much or not exercising. Everything has a balance.”

Patients might wonder what they did to cause their illness. A balanced healthcare culture will offer patient populations the opportunity to engage in culturally appropriate activities that enhance health, such as huge community walks and marathons, she adds.

The program has a diabetes grief group for patients who have undergone amputations because of their high glucose levels.

Case managers and health coaches spend a lot of time with patients who experience substance use, psychological, and family/social issues that make their diabetes diagnosis especially difficult, Haven says. “We spend a lot of time with those patients, offering them our resources and outside resources, as well,” she says.

Nearly one-third of the population served in the diabetes program do not have running water or electricity. Some patients have to go to a community house to fill water jugs for bathing and to water their animals, Haven explains.

Case managers ask patients if they have electricity because they are supposed to keep their insulin cool. When Haven asked one woman this question, she replied that she keeps her insulin in a box that she buries in the ground to keep it cool.

“When we give Baa Hózhó care, we don’t give it equally,” she says. “It’s equitable care, but we cannot give the same care to everyone and have it be the best care for everyone.”

The goal is for case managers and health coaches to get to know their patients, understand their needs, and tailor care based on each patient’s needs and wants, she adds.