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Health CoachingHelp Patients Take Charge of Their Health

Learning Objectives
1. Identify steps to develop and implement the health coaching model for your practice
2. Discuss methods to recruit, train, and mentor health coaches
3. Describe how to evaluate and track health coaches' progress over time
0.5 Credit CME
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Learning Objectives

  1. Identify steps to develop and implement the health coaching model for your practice

  2. Discuss methods to recruit, train, and mentor health coaches

  3. Describe how to evaluate and track health coaches' progress over time

Introduction

Health coaching is a team-based approach that helps patients gain the knowledge, skills, and confidence to become active participants in their care. The old saying, “Give a man a fish, and he eats for a day. Teach a man to fish, and he eats for a lifetime,” demonstrates the difference between rescuing a patient and coaching a patient. Patients with chronic conditions need to learn how to fish. Health coaching can be supplemented with health literacy strategies and effective communication techniques, such as ask–tell–ask, teach-back, and/or action planning to ensure patients understand their care plans and help them achieve their goals.

Working collaboratively with patients on health care decisions can improve lifestyle choices and prompt behavior change. The physician can delegate the personalized planning task to a team member (a health coach) who engages with patients (and their families) who have chronic conditions or complex health needs. Research shows that health coaching has a significant positive impact on patient health.13Quiz Ref IDHaving a health coach as part of the team may help the practice meet quality metrics, improve patient satisfaction and behavior change, and free up physician time.

Four STEPS to Implement Health Coaching in Your Practice

  1. Commit to Health Coaching

  2. Build the Health Coaching Model

  3. Recruit, Train, and Mentor the Coaches

  4. Start Coaching and Track Your Progress

STEP 1 Commit to Health Coaching

Practice leadership and care team support is essential to health coaching because of the resources required to accomplish the following:

  • Train health coaches

  • Develop the program

  • Create the workflows that make health coaching a regular feature of the practice

Health coaches can be trained front desk team members, medical assistants (MAs), or nurses who work in the clinical setting to integrate behavior change strategies into chronic illness care and prevention. Many health coaches also use registries to manage population health. We recommend that you check with your state professional regulation agencies to determine who can be a health coach in your state, as laws and scopes of practice may vary.

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Q&A

  • How will a health coach benefit my patients?

    Health coaching helps improve health outcomes by ensuring that patients understand their care plans. Two randomized controlled trials showed improvements in HbA1c and LDL-cholesterol management in patients who received health coaching compared with controls who did not receive coaching.1 Health coaching also improves medication adherence and increases patients' trust in their physician.1 In another randomized controlled trial, patients working with health coaches reported greater satisfaction with their care than patients without health coaches.2

  • Will I need to redesign my clinic layout or exam room space for health coaching conversations?

    Often a physician will refer patients with conditions such as diabetes or obesity to the health coach, and the patient will see the health coach right away in the exam room. Follow-up health coaching sessions can often be done over the phone. In some practices, the health coach may also have office hours or hold scheduled group sessions.

  • How could a health coaching program impact the business aspects of my practice?

    Some practices have recognized a positive business case for health coaching. This depends on several factors:

  • What impact will hiring or training a health coach have on physicians in my practice?

    Physicians rarely have the time to:

    • Do collaborative patient education

    • Close the loop to assess patient's understanding of diagnosis and treatment plan

    • Engage patients in behavior-change action plans

    These items can be accomplished by a health coach, which can increase both available physician time and physician professional satisfaction. In a survey of physicians working with health coaches, physicians rated patient visits with health coaches as less demanding than visits without health coaches.2

STEP 2 Build the Health Coaching Model

Quiz Ref IDFirst, choose the right leader for your health coaching program. The leader may be a nurse, nursing supervisor, nurse practitioner, or physician. This person should be well-versed in the tactics and goals of health coaching and be available to mentor and support the team.

Next, develop a workflow that suits your practice. Work with practice leaders to analyze your patient data to identify the greatest opportunity to make a difference with health coaching. Quiz Ref IDConsider the following when building your model:

  • Which patients will receive health coaching

  • How many patients will be in the coach's panel

  • Referral mechanism (ie, who refers the patient to the health coach)

  • Relationship with health coach (eg, duration, frequency, method of contact)

  • Your practice's staffing model

See below for a typical health coach workflow:

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Q&A

  • How do I identify patients who would benefit from health coaching?

    You may identify some patients during their appointments—patients who have had difficulty achieving their health goals or who face barriers to understanding or adhering to treatment recommendations. You may also want to search your electronic health record (EHR) to identify patients before their scheduled appointments. Look for patients with the health characteristics that your practice is targeting.

    Conditions for coaching will vary by specialty. Common conditions in primary care that can be impacted by health coaching include:

    Your team members may also know of patients who are routinely unable to meet a physician's recommendations. Consult with your nurses or medical assistants during pre-clinic huddles to help identify patients on the day's schedule for targeted coaching. In addition, you could consider including questions about health behaviors and health literacy on a pre-registration form to predict which new patients may benefit from early intervention by a health coach.

  • How many patients should each coach work with?

    It depends on your practice's model. Each health coach may have anywhere from 70 to 100 patients in their panel.35 Patients with high acuity, lack of a support network, and poly-chronic conditions may benefit from more hands-on attention and follow-through, so a coach who works with these types of patients may need to have a smaller panel. Using telemedicine can also increase the number of patients that can be followed by the health coach.

  • Can the health coaching be done by the rooming and discharge team?

    Yes, if your state's scope of practice law allows for it. Some practices elect to have the nurse or medical assistant who rooms the patient remain with the patient during the physician component of the visit (often helping with documentation) and then stay with the patient after the physician leaves to initiate a health coaching session. In this model, the health coach is especially knowledgeable about the care plan because he or she remained in the room with the patient and the physician as the plan was developed. This approach supports a high level of trust and strengthens the relationship between the patient and health coach. In addition, less time is required for handoffs between team members.

  • Should the practice consider legal issues?

    Yes, it is strongly suggested that the practice consult with knowledgeable legal counsel in your state to advise on legal issues from both a state and federal perspective (eg, privacy, scope of practice, coding and billing, and other matters).

STEP 3 Recruit, Train, and Mentor the Coaches

Quiz Ref IDCoaches are chosen to fill the health coach role for a portion of their workday and may be registered nurses (RNs), licensed practical nurses (LPNs), medical assistants, health educators, or community health workers—depending on the laws in your state. Your current staffing model may support the transition of a current team member into a health coach role.

You may also consider recruiting pre-medical or pre-nursing student interns to serve as volunteer health coaches.6 However, if you engage non-employees such as interns and volunteers, you will need to put in place confidentiality agreements and agreements indicating an educational purpose for unpaid work.

Health coach training should be comprehensive and cover:

  • Expectations of the health coach role

  • Where the coaching interaction with patients fits into a standard office visit

  • How and when the coach should interact with the rest of the care team

  • How to use your practice's EHR to enter necessary information, set up alerts, and document the health coaching visit

  • A thorough explanation of the target patient population and any skills needed to manage it, such as diagnosis terminology, available treatments and interventions, suggested lifestyle modifications, relevant laboratory tests, and commonly prescribed medications

  • How to have a supportive, collaborative, and action-oriented interaction with patients

  • Motivational interviewing to a level of proficiency and comfort when working with patients

  • Techniques such as ask–tell–ask, teach-back (also known as “closing the loop”), and action planning (see downloadable tools and Q&A below)

  • Health literacy and how to engage patients with low health literacy, such as the proper use of teaching aids and handouts

  • The basics of medication nonadherence and medication reconciliation to help patients become adherent

  • Legal and regulatory requirements under applicable laws (eg, HIPAA and state privacy laws), with the input and advice of appropriate legal counsel

Use the following downloadable tools to help train new and developing health coaches:

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Q&A

  • What educational background should health coaches have?

    The educational background your health coaches need depends on the role you expect them to perform and any requirements set forth by your state. For example, if your health coaches are going to provide clinical education, a nurse or social worker may be a good option. If the health coach will reinforce the physician's plan of care and use phone calls to keep patients committed to their treatment regimens, someone without a clinical license could acquire that skillset.

    Medical assistants have successfully filled this role and were able to help patients improve HbA1c and LDL levels in a randomized controlled trial.4 Once your health coaching program has been established and proven to be successful, you may opt to select patients who have met their health goals to become peer coaches.7 Peer health coaches should have the same illness and similar backgrounds to the patients they are coaching.7

  • What additional communication and health literacy techniques can be helpful in health coaching?

    Many patients leave the physician visit without understanding or remembering what their doctor said. If patients are asked to repeat what the physician wants them to do, patients are more likely to adhere to the physician's advice.

    There are 3 main techniques used in health coaching to help close the loop on a visit:

    Ask–tell–ask is the foundational technique for health coaching. It creates a collaborative relationship between patient and coach that encourages patient participation.8 An ask–tell–ask dialogue begins with the health coach asking patients open-ended questions to assess what they understand (or don't understand) about their care plan before sharing information.8 Based on the patient's response, the health coach then tailors information to the patient's level of understanding and briefly tells them what they would like to know.8 Then it's time to ask another question.

    Coaches may ask a patient:

    • What is your number-one health concern?

    • What do you believe you can do to improve your health?

    • How can I help you improve your health?

    • What do you know about diabetes?

    • Do you know what your A1c goal is?

    • Do you know how to bring down your A1c?

    Teach-back, also called “closing the loop,” is another technique that health coaches use to assess understanding.9 Teach-back uses plain language to explain the physician's recommendations and asks patients to tell the coach in their own words what they understood about the visit and plan of care.9

    Action planning can also be used to promote healthy behavior change.10 A randomized controlled trial with diabetic patients found that action planning, rather than telling patients what to do, is associated with significant improvement in HbA1c.1 For example, one of your patients with diabetes eats a pint of ice cream every night. You explain that she needs to lower her A1c levels and she is motivated to make the change. Telling her to stop eating ice cream will likely fail, but engaging her in a realistic action plan that includes achievable lifestyle changes, such as reducing her ice cream consumption to half a pint each night, is more likely to succeed. The method seeks to build upon a series of small successes rather than taking an “all or nothing” approach to changing patient behaviors.10

    Health coaches should also be trained to be positive, thoughtful, and empathetic with their patients. Choosing the right person for the job is often as much about holding an interest in partnering with patients to achieve their goals and having the right temperament for the job as it is about knowledge about chronic disease and wellness.

STEP 4 Start Coaching and Track Your Progress

Introduce your patients to the health coach and explain the goals of the program to them so it is easier to implement. Let scheduled patients know that they can expect to meet their new health coach at their upcoming visit. A phone call from the health coach or a warm handoff from the physician can put patients at ease and show the practice's commitment to partnering with them to improve their health.

Quiz Ref IDYou may choose to evaluate your program's success with some of the following indicators:

  • Health coaches' completed training and continued education

  • Health improvements in the targeted patient population

  • Number of appropriate patients referred to a health coach

  • Health coaching program patient recruitment and retention rates/numbers

  • Percentage of successful patient contacts made within determined recommended frequency

  • Increased patient satisfaction and engagement

  • Reduced practitioner stress

This checklist can be used in the direct observation of the health coaches to ensure that they are correctly using their coaching techniques and achieving the desired impact with patients.

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Q&A

  • Should we start by piloting our health coaching model?

    Piloting the model is a great way to start and allows you to confirm that the desired impact is achieved before expanding the model to more providers, pods, or practices within your organization. We recommend picking one practitioner to refer a small subset of patients to the health coach. This subset could be patients with a specific condition or a set number of patients with a variety of conditions. With this approach, you can see if there are any obstacles in the health coach referral process, address any issues with the coaching process, and gauge patient receptiveness to the program. Based on feedback from everyone involved in the pilot, you can refine your program for expansion.

  • How often should we evaluate the model?

    Evaluate the health coaching program regularly to confirm its impact and evaluate its success.

    Consider examining the following over time:

    • Percentage of diabetic patients in your practice whose smoking status has changed after health coaching

    • Physical activity scores or number of steps per day for patients before and after they receive health coaching

    A visual display of results, such as on a run chart, will help the team see quickly whether their efforts are moving in the right direction. For more information about continuous improvement, check out these AMA STEPS Forward™ toolkits: Change Initiatives, Change Management and Organizational Development, Lean Health Care, Plan–Do–Study–Act (PDSA), LISTEN–SORT–EMPOWER, and Getting Rid of Stupid Stuff.

Conclusion

Health coaching is a collaborative approach to care that informs, engages, and activates patients to take a prominent role in managing their health. By bridging the gap between the physician and patient, health coaches can help practices improve patient engagement in their care, leading to healthier patients with better outcomes.

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AMA Pearls

AMA Pearls

Effective health coaches can have varied backgrounds.

Anyone on your care team, including nurses, medical assistants, or even a care coordinator without clinical training, can be an effective coach.

The goal is patient engagement and motivation.

Health coaching helps patients build skills they need to take charge of their own health and provides a support system for the teachings to have a lasting impact.

Improved outcomes are a bonus for both the patient and clinician.

Physicians can rest assured that their recommendations are being communicated in a way that patients can understand and follow. Engaged and motivated patients have better outcomes.

Further Reading

Journal Articles and Other Publications

  • Goldman ML, Ghorob A, Hessler D, Yamamoto R, Thom DH, Bodenheimer T. Are low-income peer health coaches able to master and utilize evidence-based coaching? Ann Fam Med. 2015;13 Suppl 1(Suppl 1):S36-S41. doi:10.1370/afm.1756

  • University of California San Francisco Center for Excellence in Primary Care. The 10 building blocks of primary care: Health coaching in primary care – intervention protocol. 2014. http://cepc.ucsf.edu/sites/cepc.ucsf.edu/files/Health_Coaching_Protocol_14-0603.pdf* Schillinger D, Piette J, Grumbach K, et al. Closing the loop: Physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163(1):83-90. doi:10.1001/archinte.163.1.83

  • Naik AD, Palmer N, Petersen NJ, et al. Comparative effectiveness of goal setting in diabetes mellitus group clinics: Randomized clinical trial. Arch Intern Med. 2011;171(5):453-459. doi:10.1001/archinternmed.2011.70

  • Ghorob A. Health coaching: Teaching patients to fish. Fam Pract Manag. 2013;20(3):40-42. http://www.aafp.org/fpm/2013/0500/p40.html

  • Thom DH, Hessler D, Willard-Grace R, et al. Does health coaching change patients' trust in their primary care provider? Patient Educ Couns. 2014;96(1):135-138. doi:10.1016/j.pec.2014.03.018

  • Markert C, Sasangohar F, Mortazavi BJ, Fields S. The use of telehealth technology to support health coaching for older adults: literature review. JMIR Hum Factors. 2021;8(1):e23796. doi:10.2196/23796

  • Gastala NM, Wingrove PM, Gaglioti AH, Liaw W, Bazemore A. The growing trend of health coaches in team-based primary care training: a multicenter pilot study. Fam Med. 2018;50(7):526-530. doi:10.22454/FamMed.2018.459897

Websites

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Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of 0.50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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References
1.
Wayne  N, Perez  DF, Kaplan  DM, Ritvo  P. (2015).  Health coaching reduces HbA1c in type 2 diabetic patients from a lower-socioeconomic status community: A randomized trial.  J Med Internet Res. 2015;17(10):e224. doi:10.2196/jmir.4871Google ScholarCrossref
2.
Djuric  Z, Segar  M, Orizondo  C,  et al. (2017).  Delivery of health coaching by medical assistants in primary care.  J Am Board Fam Med. 2017;30(3):362–370. doi:10.3122/jabfm.2017.03.160321Google ScholarCrossref
3.
Thom  DH, Ghorob  A, Hessler  D, De Vore  D, Chen  E, Bodenheimer  TA.  Impact of peer health coaching on glycemic control in low-income patients with diabetes.  Ann Fam Med. 2013;11(2):137–144. doi:10.1370/afm.1443Google ScholarCrossref
4.
Willard-Grace  R, Chen  EH, Hessler  D,  et al.  Health coaching by medical assistants to improve control of diabetes, hypertension, and hyperlipidemia in low-income patients.  Ann Fam Med. 2015;13(2):130–138. doi:10.1370/afm.1768Google ScholarCrossref
5.
Thom  DH, Willard-Grace  R, Hessler  D,  et al.  The impact of health coaching on medication adherence in patients with poorly controlled diabetes, hypertension, and/or hyperlipidemia: A randomized control trial.  J Am Board Fam Med. 2015;28(1):38–45. doi:10.3122/jabfm.2015.01.140123Google ScholarCrossref
6.
Polak  R, Finkelstein  A, Axelrod  T,  et al.  Medical students as health coaches: Implementation of a student-initiated Lifestyle Medicine curriculum.  Isr J Health Policy Res. 2017;6(1):42. doi:10.1186/s13584-017-0167-yGoogle ScholarCrossref
7.
Dubé  K, Willard-Grace  R, O'Connell  B,  et al.  Clinician perspectives on working with health coaches: A mixed methods approach.  Fam Syst Health. 2015;33(3):213–221. doi:10.1037/fsh0000110Google ScholarCrossref
8.
University of California San Francisco Center for Excellence in Primary Care.  The 10 building blocks of primary care: “Ask Tell Ask” sample curriculum. 2014. Accessed February 14, 2021. http://cepc.ucsf.edu/sites/cepc.ucsf.edu/files/Curriculum_sample_14-0602.pdf9.
9.
 Always use teach-back! Institute for Healthcare Advancement. Accessed February 14, 2021. http://www.teachbacktraining.org/home10.
10.
University of California San Francisco Center for Excellence in Primary Care.  The 10 building blocks of primary care: “My Action Plan” sample curriculum. 2014. Accessed February 14, 2021. https://cepc.ucsf.edu/sites/cepc.ucsf.edu/files/Action_Plans_14-0602.pdf

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