Introduction

With healthcare reform on the top of the list for politicians, providers, and patients alike, the time is ripe for multiple levels of innovation. The search for cost-saving interventions that simultaneously improve patient engagement and clinical outcomes should be one of our top priorities. One such intervention that is primed to take the spotlight is a health coaching model that relies on the integration of non-clinical staff into the primary care setting.  

Making the Case for Health Coaching
Today, chronic diseases and addictions are among the most prevalent, costly, and preventable of all health problems in the US.¹ As a result, the clear majority of the treatment plan rests in the hands of the patient after they leave the clinic, including follow-through with challenging lifestyle changes and complex medication regimens. And yet, only about 50% of patients with chronic conditions are able/willing to adhere to their treatment plan on average.² There has long been a need for a concerted focus on the implementation of effective behavior change interventions into every healthcare setting. In fact, a World Health Organization review of adherence behaviors noted that “increasing adherence may have a greater effect on health than improvements in specific medical therapy”.¹

Moreover, behavior change theories and models have evolved and are well-researched in the behavior change science domain. Evidence-based health education interventions have moved away from the traditional information-based and advice-giving model to one that embraces and addresses the complex interaction of motivations, cues to action, perception of benefits and consequences, environmental and cultural influences, expectancies, self-efficacy and personal agency, state of readiness to change, ambivalence, and implementation intentions.³ The stage is set for well-trained and skilled health coaches to deliver these strategies with patients who are struggling with their treatment plan as health coaching has been studied long enough to merit confidence. A recent compendium of the health and wellness coaching literature yielded the summary that health coaching is a promising intervention for chronic disease management.⁴

Using the Most Effective Health Coaching Model

Like any other clinical skill, to effect meaningful clinical outcomes, health coaching should be based on an evidence-based approach. Currently, motivational interviewing (MI) is the only health coaching approach to be fully described, standardized, and consistently associated with positive clinical outcomes.^5-8 It has been adapted successfully in the primary care setting,⁹ and proven more time effective than traditional patient education.¹⁰ For more information on the utilization of MI in the healthcare setting, see our blog titled, Making the Case for Adopting the Motivational Interviewing Approach in the HealthCare Setting.

Exploring the Benefits of Using a Non-Clinical Health Coach

There are many advantages to using a non-clinical health coach instead of expecting the clinician to perform the health coaching intervention:

Type of proficiency needed. To become an effective change agent, medical practitioners would need a different set of competencies then are typically offered in their initial or ongoing clinical training.¹¹ Like all communication or therapeutic approaches, MI is a complex skill set that does not lend itself to a one-and-done style of training; it takes commitment, planning, and dedicated resources to train medical staff. Like learning a foreign language, it takes practice, feedback and continuous support after the initial training over time to develop proficiency.^{12, 13} Although a minimum competency is desirable for all staff who interact with patients, clinicians should likely be reserved for the overall medical management aspects of clinical care, while providing a warm hand-off to a fully-proficient health coach for the lifestyle management aspects.  

Clinical-Effectiveness. As discussed above, effecting chronic disease management entails lifestyle management and treatment adherence on the part of the patient. A trained health coach is more effective in engaging the patient and activating them to take charge of their health.^3,14 If warranted, a health coach can make the rare home visit to provide extra support to a patient. In addition, the health coach can assist during transitional care, the weakest link in the patient journey.¹⁵

Cost-Effectiveness. In a fee-for-service model, a clinician is not rewarded for spending the time needed to coach a patient who is struggling to adhere to a challenging treatment plan. In addition, there are a myriad of psychosocial issues that affect patients with chronic conditions; more time is needed to tease these out, address them, and provide appropriate resources then is feasible in a reimbursable clinical visit. Having a health coach available in the clinic to meet with the patient during the clinic visit plus schedule follow-up telephone sessions provides efficiency to the clinic flow – allowing the doctor to see more patients. In addition, there are some services, such as the Medicare Part B Annual Wellness Visit, that a medical professional – including a health educator – can administer, if they are working under the direct supervision of a physician.¹⁶ (See Figure 1: Case Study)

A Shifting System. With the increasing emergence of Accountable Care Organizations (ACO), some healthcare systems are shifting towards a pay-for-performance model and capitation.¹⁷ This emphasis on quality of care and patient satisfaction demands effective behavior change interventions for success, and a more concerted effort to empower clients and leverage patient activation – the overarching goal of MI-based health coaching. One workgroup assigned to address patient-centeredness for a coalition on ACOs identified 58 competencies for clinicians; many of which are inherent in a health coach’s training.¹⁸

In Summary

The healthcare industry in the US is in a state of flux; there are current and future challenges that include political, economic, and systemic quagmires. Integrating non-clinical health coaches into the primary care system is a positive and strife-free step that can be taken in any primary care setting, regardless of the current payment model. With the right implementation plan, your organization can realize almost immediate benefits for all stakeholders.

References

¹     Brown MT, Bussell JK. Medication adherence: WHO cares? Mayo Clin Proc. 2011 Apr;86(4):304–14. doi: 10.4065/mcp.2010.0575. Accessed July 3, 2017. Available at http://www.mayoclinicproceedings.org/article/S0025-6196(11)60007-4/fulltext.

²     Rolnick SJ, Pawloski PA, Hedblom BD, Asche SE, Bruzek RJ. Patient Characteristics Associated with Medication Adherence. Clin Med Res 2013;11:54-65. doi: 10.3121/cmr.2013.1113.

³     Linden A, Butterworth SW, Prochaska JO. Motivational interviewing-based health coaching as a chronic care intervention. J Eval Clin Prac 2010;16(1):166-174.

⁴     Sforzo GA, Kaye MP, Todorova I, et al. Compendium of the Health and Wellness Coaching Literature. Am J Lifestyle Med 2017 May 19. Accessed July 11, 2017. Available at http://journals.sagepub.com/doi/full/10.1177/1559827617708562.

⁵     Butterworth SW, Linden A, McClay W. Health Coaching as an Intervention in Health Management Programs. Dis Manage Health Out 2007;15(5):299-307.

^​6     Noordman J, van der Weijden T, van Dulmen S. Communication–related behavior change techniques used in face-to-face lifestyle interventions in primary care: a systematic review of the literature. Patient Educ Couns 2012;89(2):227-44.^​

⁷    Olsen JM, Nesbitt BJ. Health Coaching to Improve Healthy Lifestyle Behaviors: An Integrative Review. Am J Health Promot 2010;25(1):e1-e12.

⁸     Wolever RQ, Simmons LA, Sforzo GA, et al. A Systematic Review of the Literature on Health and Wellness Coaching: Defining a Key Behavioral intervention in Healthcare. Globl Adv Health Med 2013;2(4):38-57.

⁹     VanBuskirk KA, Wetherell JL. Motivational Interviewing Used in Primary Care: A Systematic Review and Meta-analysis. J Behav Med 2014;37(4):768-80.

¹⁰   Lundahl B, Burke BL. The Effectiveness and Applicability of Motivational Interviewing: A Practice-Friendly Review of Four Meta-Analyses. J Clin Psych 2009;65(11):1232-45.

¹¹   King A, Hoppe RB. “Best Practice” for Patient-Centered Communication: A Narrative Review. J Grad Med Educ 2013;5(3):385-393.

¹²   Miller WR, Rose GS. Toward a Theory of Motivational Interviewing. Am Psychol 2009;64(6):527-537.

¹³   Adelman AM. Integrating a Health Coach into Primary Care: Reflections From the Penn State Ambulatory Research Network. Ann Fam Med 2005;3(suppl_2):x33-x35.

¹⁴   Thomas ML, Elliott JE, Rao SM, Fahey KF, Paul SM, Miaskowski C. A Randomized, Clinical Trial of Education or Motivational-Interviewing-Based Coaching Compared to Usual Care to Improve Cancer Pain Management. Oncology Nursing Forum. 2011;39(1):39–49.

¹⁵   Proctor L. ACO Care Transitions: Coaching, Management, and Coordination [Internet]. PSQH. [cited 2017Jun14]. Available from: https://www.psqh.com/analysis/aco-care-transitions-coaching-management-and-coordination/

¹⁶   Centers for Medicare & Medicaid Services. The ABCs of the Annual Wellness Visit (AWV). The ABCs of the Annual Wellness Visit (AWV) 2015. Accessed July 11, 2017.  Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/AWV_chart_ICN905706.pdf

¹⁷   Muhlestein D, Saunders R, McClellan M. Growth of ACOs and Alternative Payment Models in 2017. Health Affairs Blog 2017 June 28. Accessed on July 11, 2017. Available at http://healthaffairs.org/blog/2017/06/28/growth-of-acos-and-alternative-payment-models-in-2017/

¹⁸   Accountable Care Learning Collaborative at Western Governors University. A Call for Collaborative Action: Identifying Required Competencies for Success in Value-Based Care. Patient-Centeredness 2016. Accessed July 11, 2017. Available at https://www.accountablecarelc.org/sites/default/files/ACLC_WhitePaper_PatientCenterdness.pdf

¹⁹   Healthcare Intelligence Network. Health Coaching in 2016: Motivational Interviewing Sparks Behavior Change Conversation. White Paper 2016. Accessed July 11, 2017. Available at http://www.hin.com/library/registerHealthCoaching2016.html.

²⁰   Chambliss ML, Lineberry S. Adding a Health Education Specialist to Your Residency – The Story: Cone Family Medicine Residency, Greensboro, NC. Accessed July 11, 2017. Available at http://slideplayer.com/slide/10333101/.