Health CoachingHelp Patients Take Charge of Their Health

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:

• 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 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

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:

• Hypertension

• Diabetes

• Obesity

• Kidney disease

• Asthma

• Chronic obstructive pulmonary disease (COPD)

• Chronic heart failure

• Behavioral health conditions

• Pain management

• Multiple, complex chronic health conditions

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.^3- 5 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).

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.

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.