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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 their progress over time
0.5 Credit CME
How will this module help me implement health coaching in my practice?

  1. Describes four STEPS to develop and roll out a health coaching program.

  2. Provides answers to common questions about health coaching.

  3. Shares tools to develop training materials and track progress.

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 (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. Quiz 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 my 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.

The support of practice leadership and the care team to health coaching is essential because of 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 lay people, 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.

Box Section Ref ID

Q&A

  • How will a health coach benefit my patients?

    Health coaching improves 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. Health coaching 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:

    • Payment model, for example, a value-based payment model will incentivize focusing on outcomes, which can be affected by health coaches and other team members.

    • Availability of revenue from patient-centered medical home (PCMH) certification and/or pay-for-performance (CCM Code, Medicare Wellness Visits).

    • Potential for increased revenue from more visits due to more available physician time.

  • 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 patients' understanding.

    • Engage patients in behavior-change action plans.

    These items can be accomplished by a health coach, which can increase available physician time and 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.

First, choose the right leader for your health coaching program. The leader may be a nurse, nursing supervisor, nurse practitioner, or physician. Quiz Ref IDThis 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 (i.e., who refers the patient to the health coach).

  • Relationship with health coach (e.g., duration, frequency, method of contact, etc.).

  • Your practice's staffing model.

You may want to download this health coaching workflow to see 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 have trouble 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:

    • Hypertension.

    • Diabetes.

    • Obesity.

    • Kidney disease.

    • Asthma.

    • Chronic obstructive pulmonary disease.

    • Chronic heart failure.

    • Behavioral health issues.

    • Multiple, complex chronic health conditions.

    Your team members may also know of patients who routinely struggle with the physician's recommendations. Consulting with your nurses or MAs during a pre-clinic huddle may help you identify patients on the day's schedule for targeted coaching. In addition, you could consider including questions about health behaviors and 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 require 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 rooming staff?

    Yes, if your state's scope of practice regulations allows for it. Some practices elect to have the nurse or MA 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.

Step 3 Recruit, train, and mentor the coaches.

Quiz Ref IDCoaches are chosen to fill the health coach role for a portion of their work day 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 staff 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, for non-employees such as interns and volunteers, you will need confidentiality agreements in place, as well as agreements indicating an educational purpose for the work for unpaid volunteers and interns.

Box Section Ref ID

Q&A

  • What educational background should the health coach have?

    The education of your health coaches 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.

    MAs 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 kind of training should we provide our health coaches?

    Health coach training should be comprehensive and cover:

    • Expectations of the health coaching 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 terminology of diagnosis, treatment or intervention, lifestyle modifications, laboratory tests, and commonly used 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 (defined 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.

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

    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 three main techniques used in health coaching to help close the loop on a visit:

    Ask-tell-ask is the foundational technique. 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 a temperament and interest in partnering with patients to achieve their goals 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:

  • Completed training and continued education for health coaches.

  • Improved health of the targeted patient population.

  • Referred appropriate patients to health coach.

  • Achieved patient recruitment into the program and retention.

  • Made successful patient contacts according to the determined frequency.

  • Increased patient satisfaction and engagement.

  • Reduced provider 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.

Box Section Ref ID

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 provider 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:

    • Percent 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.

    See the Plan-Do-Study-Act module for more information about continuous improvement. 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.

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.

Box Section Ref ID

AMA Pearls

Effective health coaches can have varied backgrounds.

Anyone on your care team, including nurses, MAs, 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 provider.

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.

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Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

0.5 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;

0.5 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;

0.5 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program; and

0.5 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program;

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Article Information

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of .50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Target Audience: This activity is designed to meet the educational needs of practicing physicians, practice administrators, and allied health staff.

*Disclaimer: Individuals below who are marked with an asterisk contributed towards Version 1 of this learning activity.

Statement of Competency: This activity is designed to address the following ABMS/ACGME competencies: practice-based learning and improvement, interpersonal and communications skills, professionalism, systems-based practice, interdisciplinary teamwork, quality improvement and informatics.

Planning Committee:

  • Christine A. Sinsky, MD, FACP, Vice President, Professional Satisfaction, American Medical Association*

  • Marie Brown, MD, MACP, Senior Physician Advisor, Professional Satisfaction and Practice Sustainability, American Medical Association & Associate Professor, Rush Medical College, Rush University Medical Center

  • Renee DuBois, MPH, Senior Practice Transformation Advisor, Professional Satisfaction and Practice Sustainability, American Medical Association

  • Brittany Thele, MS, Program Administrator, Professional Satisfaction and Practice Sustainability, American Medical Association

  • Ashley C. Cummings, MBA, CRCR, CME Program Committee, American Medical Association

  • Alejandro Aparicio, MD, Director, Medical Education Programs, American Medical Association*

  • Rita LePard, CME Program Committee, American Medical Association*

  • Becca Moran, MPH, Program Administrator, Professional Satisfaction and Practice Sustainability, American Medical Association*

  • Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, American Medical Association*

  • Jessica Reimer, PhD, Medical Writer, HealthComms, Inc.*

  • Sam Reynolds, MBA, Director, Professional Satisfaction and Practice Sustainability, American Medical Association*

Content Reviewers:

  • J. James Rohack, MD, FACC, FACP, Senior Advisor and former President, American Medical Association

  • Renee DuBois, MPH, Senior Practice Transformation Advisor, Professional Satisfaction and Practice Sustainability, American Medical Association

  • Brittany Thele, MS, Program Administrator, Professional Satisfaction and Practice Sustainability, American Medical Association

  • Jessica Reimer, PhD, Medical Writer, HealthComms, Inc.*

  • William K. Appelgate, PhD, CPC, President and Founder, Clinical Health Coach®*

  • Sarah Levy, MD, Medical Director for Continuum of Care, Division of Clinical Excellence and Integration, Group Health Physicians*

  • Becca Moran, MPH, Program Administrator, Professional Satisfaction and Practice Sustainability, American Medical Association*

  • Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, American Medical Association*

About the Professional Satisfaction and Practice Sustainability Group: The AMA Professional Satisfaction and Practice Sustainability group has been tasked with developing and promoting innovative strategies that create sustainable practices. Leveraging findings from the 2013 AMA/RAND Health study, “Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy,” and other research sources, the group developed a series of practice transformation strategies. Each has the potential to reduce or eliminate inefficiency in broader office-based physician practices and improve health outcomes, increase operational productivity and reduce health care costs.

Disclosure statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

The project described was supported by Funding Opportunity Number CMS-1L1-15-002 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

ABMS MOC: Through the American Board of Medical Specialties (“ABMS”) ongoing commitment to increase access to practice relevant Maintenance of Certification (“MOC”) Activities, this activity has met the requirements as an MOC Part II CME Activity. Please review the ABMS Continuing Certification Directory to see what ABMS Member Boards have accepted this activity.

Renewal Date: 04/25/2019

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