The COACH Model: A Care Management Intervention to Engage and Empower Patients

Statement of Problem

Across the country, data demonstrates that children and adults facing high social and environmental needs have more frequent emergency room visits and hospital admissions, resulting in higher costs. Dr. Jeff Brenner, founder of the Camden Coalition of Healthcare Providers, saw this trend reflected in his own practice: 30% of hospital costs in Camden, N.J., were coming from only 1% of patients. Further analyses in Camden found that many of these medically and socially complex patients habitually frequented the emergency room for easily treatable conditions, and often sought care for advanced conditions that could have been prevented through early diagnosis and care management. This issue is garnering attention from pediatric institutions interested in finding ways to effectively support children with complex conditions and their families. 


Through direct experience with patients—as well as partnerships with hospitals, primary care providers and community representatives—founding Camden Coalition staff developed a care management intervention for patients with complex medical and social issues called COACH. COACH is a set of techniques and tools that can be used by an interdisciplinary health care team to empower medically and socially complex patients to best manage their health conditions and engage in preventive care.

COACH stands for:

C: Connect tasks with vision and priorities
O: Observe the normal routine
A: Assume a coaching style
C: Create a backwards plan
H: Highlight progress with data

A care team—comprised of a nurse, community health worker and social worker—use the COACH model to work with patients on a weekly basis to address their complex medical and social needs. At the core of the model is the development of an Authentic Healing Relationship between the patient and the care team, which supports patients in working toward sustained behavior change and long-term health management.

With expertise in tool development and organizational management, PolicyLab worked closely with an interdisciplinary team at the Camden Coalition to codify the COACH intervention into a reference guide and manual. This innovative approach to care, created and refined organically by way of real patient experiences, is now recorded and translatable, facilitating its use in a wide range of settings.

With the COACH manual in place, PolicyLab’s qualitative research team then partnered with a cross-disciplinary team at the Camden Coalition to develop a fidelity tool that measures adherence to the COACH model. PolicyLab staff conducted multiple rounds of in-depth interviews,  focus groups with staff and supervisors, and accompanied teams on home visits to devise the items for the fidelity tool. The goal of this tool is to guide and assess the successful implementation of COACH. The tool can be used for training purposes for new staff, as well as ensuring fidelity as the COACH model is implemented in new communities and settings. 

Next Steps

Leadership at the Camden Coalition and team members at PolicyLab are working together to identify grant opportunities to pilot both the manual and fidelity tool in new settings to understand where adaptations might be necessary.

This project page was last updated in September 2021.

Suggested Citation

Children's Hospital of Philadelphia, PolicyLab.The COACH Model: A Care Management Intervention to Engage and Empower Patients [Online]. Available at: [Accessed: plug in date accessed here].