Behavioral Health Coach
Newton-Wellesley Hospital(NWH)

Job Info

As an integral member Population Health ManagementInitiative, the Population Health Behavioral Coach assists in theintegration of behavioral health in the primary care setting and is supportiveof other Population Health Management initiatives.

Consistent with a Patient Centered Medical Home (PCMH) teambased care model, the Population HealthBehavioral Health Coach collaborates with all members of the PopulationHealth Management Team including providers in the primary care practice andconsultative mental health disciplines to provide behavioral health management for adults. The coach willwork collaboratively with a multi-disciplinary team to implement evidence-basedservices for primary care patients utilizing tools and training from the IMPACTCollaborative Care model and Partners HealthCare sources.

This position requires a strong working knowledge ofcoaching techniques including motivational interviewing and behavioralactivation as well as common mental health conditions, psychosocial issues and chronicdiseases which impact overall health and well-being. Experience should includea minimum of two years of experience in a mental health setting.

The Population Health Behavioral Coach should demonstrate prudentclinical judgment based on established professional standards and guidelines,effective problem solving skills, critical thinking, and strong organizationaland interpersonal skills experience with team based care, creativity,flexibility, and the ability to multi-task. The Population Health Behavioral Coach will be centrally (NewtonWellesley) and practice based.

Patient Centered


  • Triage referrals from primary care clinicians to theconsultative team
  • Assess patients for common mental health and substance abuseconditions.
  • Identifies psychosocial, financial, legal, psychiatric orsubstance use issues that affect patient care management and collaborates withthe team to support and facilitate the patient care process.
  • Ensure systematic screening of adults for depression, usingevidence-based screening tools.

Coordination and Communication

  • Coordinate with the behavioral health team and providecoaching support for a panel of adults with defined behavioral health needs.
  • Systematically review the caseload with the consultingpsychiatrist and LICSW each week.
  • Effectively communicate treatment recommendations,assessment, and case recommendations to the referring primary care team.
  • Facilitate discussion of treatment plan changes whenpatients are not improving.
  • Support the primary care provider in outreach to establishedmental health providers for patients already engaged in treatment.

Intervention, engagementand surveillance

  • Provide brief interventions using evidence-based techniquessuch as Behavioral Activation, Problem-Solving Treatment, MotivationalInterviewing, or other treatment appropriate for the primary care setting.
  • Monitor patients (in person or phone) for changes inclinical symptoms and treatment side effects.
  • Support psychotropic medication management prescribed byPCPs, focusing on adherence, side effects, complications and effectiveness.
  • Actively facilitate patient engagement and follow-up incare.
  • Provide education to patients using a variety of educationalmaterials.
  • Develop maintenance plan with patients to help ensure ahealthy lifestyle once in remission.
  • Provide, or facilitate outside referrals to community basedmental health and community support services.


• Support the implementation and ongoing integration ofbehavioral health and psycho-social services in primary practices.

• Track resources specific referral volume and provide summarylevel report on a periodic basis.

  • Serve as the lead on maintaining accurate and up-to-datelogs and standardized, data entry and works under the supervision of the teamlead and central team in completing process metrics.
  • Educate primary care team on evidence based coaching modelsincluding motivational interviewing and behavioral activation. Activelyparticipates in educating care team members, including PCPs and support staffon psychiatric conditions (with a focus on depression and anxiety).
  • May serve as the NWPHO representative on central teaminitiatives related to behavioral health initiatives.

    Responsible for identifying available behavioral health andsocial support resources in our local community and helps build and maintainstrong referral relationships with these providers.

    Exemplifies the Patient Centered Medical Home collaborative,integrated care philosophy and acts as a role model for patients by practicingbehaviors consistent with this focus.

    Maintains confidentiality and complies with the NASW Code ofEthics according to professional and department standards.

    Documents relevant information in a timely manner.

    Performs other duties as required.

  • Bachelors with two years of experience in a mental healthsetting
  • Masters degree preferred in Social Work or Mental HealthCounseling

  • Two years of previous experience in a mental health settingpreferred
  • Background or familiarity with
    • Motivational interviewing and coaching
    • Behavioral activation
    • Depression and anxiety management
    • Addiction and substance abuse
    • Management of patients with complex medical conditions
  • Experience working with a variety of community agencies andresources preferred
  • Ability to work effectively in a complex, fast paced medicalenvironment and multiple practice locations

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